Introduction

The NY State of Health 2015 Plan Compare provides information about health plans
offered on the Individual Marketplace. Here's some general information to get you
started.
Metal Levels: Plans offered on the NY State of Health are available at four metal
levels: Platinum, Gold, Silver and Bronze. Platinum plans have the lowest out-of-pocket
cost if you use a service, but the highest premium. Bronze plans have the highest outof- pocket cost, but the lowest premium.
Covered Services: All plans offered on the Marketplace cover 10 Essential Health
Benefits:

Ambulatory Patient Services

Emergency Services
Inpatient Care
Maternity and New Born Care
Mental Health and Substance Use Services
Prescription Drugs
Rehabilitative Care
Laboratory Services
Preventive, Wellness and Chronic Disease Management
Pediatric Services, including vision care

Standard and Non-Standard Plans: NY State of Health offers two types of plans:
standard plans and non-standard plans. To make it easier to compare options,
standard plans cover the same services and have the same out-of-pocket costs
regardless of the insurer. The primary differences are the monthly premium charged by
the insurer, the insurers provider network and prescription drug formulary, and the
plans quality rating.
Non-standard plans were designed to give you additional choices. Non-standard plans
cover the same ten Essential Health Benefits as the standard plan, but they may also
cover extra services like dental and/or vision care for adults. Non-standard plan may
also have different out-of-pocket costs.

How to Use the NYSOH Plan Compare

The Plan Compare is organized by county. Find the section for the county in which
you reside. It will include information about all of the health plan options available
to you and your family through the Marketplace.

The Table of Contents below provides the pages in which your county can be
located. Also, to find your county, or a particular insurer, you can use the Find
feature. For Internet Explorer, this can be found by right clicking within the PDF,
then clicking Find and typing in your county or insurer. For Google Chrome, this
can be found in the upper right hand corner of the browser, click it, click on the
Find feature and type in your county or insurer.

At the top of each page, you will find information that identifies the name of the
insurer, the name of the plan, the plans identification number and the metal level.
The Plan Compare allows you to preview all of the plan options in your county, or
select plans offered by certain insurers or at certain metal levels.

Each page in the Health Plan Compare shows the standard plan and the plan
you are reviewing so you can see how it compares. Pay particular attention to
any difference in out-of-pocket costs and any additional services covered by the
plan.

The Plan Compare does not include monthly premium because the amount you
will pay each month will depend on your income and family size when you apply for
coverage. To see if you may qualify for financial assistance to reduce your
monthly cost, visit the NY State of Health website.

You can review the Plan Compare while you are on the website, or if it is more
convenient you can print one or more pages and review them later.
The Health Plan Compare is intended to allow you to preview the plans offered on the
Individual Marketplace. Before you select and enroll in a health plan, find out which
health care providers participate in the health plans network and, if you take
medication, find out if they are covered by the health plans formulary or list of covered
drugs.
You can find the plans customer service numbers and provider directory links on our
website at: http://info.nystateofhealth.ny.gov/resource/health-plan-customer-servicephone-numbers-and-provider-networks
Questions or need assistance? Visit our website at www.nystateofhealth.ny.gov, call
our Customer Service Center at 1-855-355-5777 or meet with a NY State of Health inperson assistor in your area.

TABLE OF CONTENTS
COUNTY
Albany

PAGES
6 247

Allegany

248 388

Bronx

389 721

Broome

722 860

Cattaraugus

861 1001

Cayuga

1002 1136

Chautauqua

1137 1277

Chemung

1278 1320

Chenango

1321 1445

Clinton

1446 1549

Columbia

1550 1762

Cortland

1763 1857

Delaware

1858 2056

Dutchess

2057 2291

Erie

2292 2452

Essex

2453 2648

Franklin

2649 2705

Fulton

2706 2867

Genesee

2868 3022

Greene

3023 3235

Hamilton

3236 3370

Herkimer

3371 3453

Jefferson

3454 3510

Kings

3511 3843

Lewis

3844 3938

Livingston

3939 4059

Madison

4060 4184

Monroe

4185 4319

Montgomery

4320 4505

Nassau

4506 4788

New York

4789 5081

Niagara

5082 5240

Oneida

5241 5415

Onondaga

5416 - 5552

Ontario

5553 5687

Orange

5688 5950

Orleans

5951 6129

Oswego

6130 6264

Otsego

6265 6361

Putnam

6362 6544

Queens

6545 6877

Rensselaer

6878 7119

Richmond

7120 7402

Rockland

7403 7691

Saratoga

7692 7911

Schenectady

7912 8123

Schoharie

8124 8229

Schuyler

8230 8272

Seneca

8273 8407

St. Lawrence

8408 -- 8464

Steuben

8465 8521

Suffolk

8522 8804

Sullivan

8805 8987

Tioga

8988 9074

Tompkins

9075 9155

Ulster

9156 9376

Warren

9377 9588

Washington

9589 9800

Wayne

9801 9943

Westchester

9944 10250

Wyoming

10251 10443

Yates

10444 10578

Albany County
Individual Market Products

Plan

Standard

Non-Standard

Blue Shield of NENY

Capital District Physicians Health Plan

(CDPHP)

Emblem Health

Empire Blue Cross

Fidelis

Health Republic

MVP

Wellcare

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 36346NY0480001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 36346NY0480026
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep25
HIOS Plan ID: 36346NY0480035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 36346NY0480002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 36346NY0480027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 36346NY0480036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: HDHP-HSA 270, Bronze, NS, OON, Dep25
HIOS Plan ID: 36346NY0480006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,000
$10,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
$50 copayment
$80 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

$250 Wellness Card

$250 Wellness Card

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: BlueShield of Northeastern NY

Product Name: HDHP-HSA 270, Bronze, NS, OON, Dep29
HIOS Plan ID: 36346NY0480007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,000
$10,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
$50 copayment
$80 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

$250 Wellness Card

$250 Wellness Card

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: BlueShield of Northeastern NY

Product Name: HDHP-HSA 269, Silver, NS, OON, Dep25
HIOS Plan ID: 36346NY0480019
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$35 copayment
$70 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

$250 Wellness Card

$250 Wellness Card

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: BlueShield of Northeastern NY

Product Name: HDHP-HSA 269, Silver, NS, OON, Dep29
HIOS Plan ID: 36346NY0480020
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$35 copayment
$70 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

$250 Wellness Card

$250 Wellness Card

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: BlueShield of Northeastern NY

Product Name: Aqua, Gold, NS, OON, Dep25
HIOS Plan ID: 36346NY0480031
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$2,000
$4,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

$250 Wellness Card

$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Aqua, Gold, NS, OON, Dep29
HIOS Plan ID: 36346NY0480032
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$2,000
$4,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

$250 Wellness Card

$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: 267, Platinum, NS, OON, Dep25
HIOS Plan ID: 36346NY0480045
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$50 copayment
$150 copayment
$100 copayment
$75 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$25 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment

$250 Wellness Card

$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: 267, Platinum, NS, OON, Dep29
HIOS Plan ID: 36346NY0480046
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$50 copayment
$150 copayment
$100 copayment
$75 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$25 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment

$250 Wellness Card

$250 Wellness Card

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep25
HIOS Plan ID: 88582NY0170001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep25
HIOS Plan ID: 88582NY0150001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Platinum Platinum ST INN Dep25
HIOS Plan ID: 88582NY0140001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep29
HIOS Plan ID: 88582NY020001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep29
HIOS Plan ID: 88582NY0260001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0290001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160011
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160013
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160017
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160029
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160003
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160005
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1,000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1,000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Health Savings Account (HSA):
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Health Savings Account (HSA):
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160103
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160105
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160111
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160113
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 1000, Gold, NS, INN, Pediatric Dental, Dep 25, a MultiState Plan
HIOS Plan ID: 80519NY0330006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 1000, Gold, NS, INN, Pediatric Dental, Dep 29, a MultiState Plan
HIOS Plan ID: 80519NY0330014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep29 Acupuncture Home Health Care
Three PCP visits are covered in full Wellness
HIOS Plan ID: 56184NY0150008-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$200 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$200 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150010
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical) $100 (Drug)

$1,700 (Medical) $200 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep29 Acupuncture Home Health
Care Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150011
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep29 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep29 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150014-01
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep25 Acupuncture Home Health

Care Three PCP visits are covered in full Wellness

HIOS Plan ID: 56184NY0150015-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$675
$1,350

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep25 Acupuncture Home Health Care

Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150018
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical)
$1,700 (Medical)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep25 Acupuncture Home

Health Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150019
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep25 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150020
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep25 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Wellcare of New York

Product Name: WellCare Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010005
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010007
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010010
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
30% coinsurance
30% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

$50 copayment

30% coinsurance

$50 copayment

30% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400

$4,000
$8,000

$30 copayment
$50 copayment
$0 copayment

$30 copayment
$40 copayment
$0

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$55 copayment
30% coinsurance
30% coinsurance
$40 copayment
25% coinsurance
$30 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$175
$350

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$15 copayment
$30 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$25 copayment
$45 copayment
$250 copayment
$75 copayment
$30 copayment
10% coinsurance
$20 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$975
$1950
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$35 copayment
$100 copayment
$75 copayment
$20 copayment
5% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
30% coinsurance
30% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

$50 copayment

30% coinsurance

$50 copayment

30% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$30 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$55 copayment
30% coinsurance
30% coinsurance
$40 copayment
25% coinsurance
$30 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$175
$350

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$15 copayment
$30 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$25 copayment
$45 copayment
$250 copayment
$75 copayment
$30 copayment
10% coinsurance
$20 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$35 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$975
$1,950
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance

$6 copayment
$15 copayment
$35 copayment
$100 copayment
$75 copayment
$20 copayment
5% coinsurance

$15 copayment

$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Allegany County
Individual Market Products

Plan

Standard

Non-Standard

BlueCross BlueShield of Western NY

Fidelis

Health Republic

Independent Health

Univera

Plan Name: BlueCross BlueShield of Western NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 49526NY0450001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 49526NY0450026
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 49526NY0450002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 49526NY0450027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 49526NY0450036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Value, Bronze, NS, INN, Dep25
HIOS Plan ID: 49526NY0450006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Value, Bronze, NS, INN, Dep29
HIOS Plan ID: 49526NY0450007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$5 copayment
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS 8100EX, Bronze, NS, OON, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450008
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS 8100EX, Bronze, NS, OON, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450009
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
$250 Wellness Card

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,300
$2,600

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,00
$4,000
$15 copayment
$25 copayment
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$20 copayment
30% coinsurance
$250 copayment
$100 copayment
$55 copayment
50% coinsurance
$15 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

$15 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$3 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$35 copayment
50% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,300
$2,600

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,00
$4,000
$15 copayment
$25 copayment
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$20 copayment
30% coinsurance
$250 copayment
$100 copayment
$55 copayment
50% coinsurance
$15 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

$15 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,00
$2,000
$10 copayment
$20 copayment
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$3 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$35 copayment
50% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Aqua, Gold, NS, OON, Dep25
HIOS Plan ID: 49526NY0450031
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$50 copayment
$50 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Aqua, Gold, NS, OON, Dep29
HIOS Plan ID: 49526NY0450032
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$50 copayment
$50 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS110, Platinum, NS, OON, Dep25
HIOS Plan ID: 49526NY0450040
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$20 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$20 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$30 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS110, Platinum, NS, OON, Dep29
HIOS Plan ID: 49526NY0450041
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$20 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$20 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$30 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
$250 Wellness Card

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Independent Health

Product Name: Standard Bronze ST OON Dep25
HIOS Plan ID: 18029NY1310009
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Gold ST OON Dep25
HIOS Plan ID: 18029NY1220001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Platinum ST OON Dep25
HIOS Plan ID: 18029NY1180001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Bronze ST OON Dep29
HIOS Plan ID: 18029NY1310010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Gold ST OON Dep29
HIOS Plan ID: 18029NY1220002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Platinum ST OON Dep29
HIOS Plan ID: 18029NY1180002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Max Bronze NS INN Dep25 Adult Vision Nurse Helpline Telemedicine Wellness
HIOS Plan ID: 18029NY1360069
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$40 copayment
25% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
50% coinsurance
50% coinsurance
25% coinsurance
25% coinsurance
$75 copayment
50% coinsurance
25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

25% coinsurance
$40 copayment
25% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: Max Bronze NS INN Dep29 Adult Vision Nurse Helpline Telemedicine Wellness
HIOS Plan ID: 18029NY1360070
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$40 copayment
25% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
50% coinsurance
50% coinsurance
25% coinsurance
25% coinsurance
$75 copayment
50% coinsurance
25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

25% coinsurance
$40 copayment
25% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$4 copayment
$30 copayment
50% copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
10% coinsurance
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
50% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$4 copayment
$30 copayment
50% copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
10% coinsurance
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
50% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Gold NS OON Dep25 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220021
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$45 copayment

$35 copayment

$25 copayment

$35 copayment

$45 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$45 copayment
$15 copayment
$45 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Gold NS OON Dep29 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220022
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$45 copayment

$35 copayment

$25 copayment

$35 copayment

$45 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$45 copayment
$15 copayment
$45 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: FlexFit Platinum NS OON Dep25 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180021
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$10 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: FlexFit Platinum NS OON Dep29 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180022
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$10 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Univera Healthcare

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0950004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0940004
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0930004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0950002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0940002
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0930002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0950012
Metal Level: Bronze
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
$ copayment

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Not covered
50% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0950014
Metal Level: Bronze
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Not covered
50% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008
Metal Level: Silver
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$15 copayment
$15 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$ copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance

$10 copayment
$10 copayment
Gym Membership
Reimbursement

Not covered
5% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010
Metal Level: Silver
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$ copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$ copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$15 copayment
$15 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$ copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance

$10 copayment
$10 copayment
Gym Membership
Reimbursement

Not covered
5% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0940014
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment

$0 copayment

$30 copayment
$30 copayment

$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0940016
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0930008
Metal Level: Platinum
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Univera

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0930010
Metal Level: Platinum
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$25 copayment
Gym Membership
Reimbursement

Bronx County
Individual Market Products

Plan

Standard

Non-Standard

Affinity

Emblem Health

Empire Blue Cross Blue Shield

Fidelis

Health Republic

Healthfirst

Metroplus

North Shore - LIJ Care Connect

Oscar

United Healthcare

Wellcare

Plan Name: Affinity Health Plan

Product Name: Affinity Access Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010003
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010013
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010011
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010010
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Bronze ST INN Dep25
HIOS Plan ID: 57165NY0020004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep25
HIOS Plan ID: 57165NY0020003
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep25
HIOS Plan ID: 57165NY0020003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep25
HIOS Plan ID: 57165NY0020003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep25
HIOS Plan ID: 57165NY0020003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Gold ST INN Dep25
HIOS Plan ID: 57165NY0020002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Platinum ST INN Dep25
HIOS Plan ID: 57165NY0020001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Bronze ST INN Dep29
HIOS Plan ID: 57165NY0020013
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep29
HIOS Plan ID: 57165NY0020012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep29
HIOS Plan ID: 57165NY0020012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep29
HIOS Plan ID: 57165NY0020012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep29
HIOS Plan ID: 57165NY0020012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Gold ST INN Dep29
HIOS Plan ID: 57165NY0020011
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Platinum ST INN Dep29
HIOS Plan ID: 57165NY0020010
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep25
HIOS Plan ID: 88582NY0170001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep25
HIOS Plan ID: 88582NY0150001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Platinum Platinum ST INN Dep25
HIOS Plan ID: 88582NY0140001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep29
HIOS Plan ID: 88582NY020001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep29
HIOS Plan ID: 88582NY0260001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0290001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness:
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330005
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness:
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160012
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160014
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160018
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160028
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160030
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160020
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160022
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160107
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160109
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160115
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160117
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$30 copayment
0% coinsurance
Not covered
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9.000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

20% coinsurance
$25 copayment
$0 copayment
No covered
$25 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$30 copayment
0% coinsurance
Not covered
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9.000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

20% coinsurance
$25 copayment
$0 copayment
No covered
$25 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: Healthfirst

Product Name: Healthfirst Bronze Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020003
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020007
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020007-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020007-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020007-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Gold Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020011
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Platinum Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020015
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Bronze Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Gold Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020012
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Platinum Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Bronze Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020052
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,000
$6,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
20% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement
Membership

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Bronze Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020053
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,000
$6,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
20% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement
Membership

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020054
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,500
$11,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020054-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020054-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020054-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020055
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,500
$11,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Gold Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020056
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$40 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$25 copayment
$25 copayment
$25 copayment
$25 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Gold Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020057
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$40 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$25 copayment
$25 copayment
$25 copayment
$25 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Platinum Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020058
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Platinum Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020059
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: MetroPlus Health Plan

Product Name: BronzePlus-B1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0040001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0040001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0040001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0040001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: GoldPlus-G1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0080001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus

Product Name: PlatinumPlus-P1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0110001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: BronzePlus-B1, ST, INN, Dep29, Pediatric Dental
HIOS Plan ID: 11177NY0010002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep29, Pediatric Dental
HIOS Plan ID: 11177NY0040002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep29, Pediatric Dental
HIOS Plan ID: 11177NY0040002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep29, Pediatric Dental
HIOS Plan ID: 11177NY0040002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep29, Pediatric Dental
HIOS Plan ID: 11177NY0040002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: GoldPlus-G1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0080002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus

Product Name: PlatinumPlus-P1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0110002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus

Product Name: BronzePlus-B2, NS, INN, Dep25, Pediatric and Adult Dental
HIOS Plan ID: 11177NY0160001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,000
$6,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement
Membership

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental

Plan Name: MetroPlus

Product Name: BronzePlus-B2, NS, INN, Dep29, Pediatric and Adult Dental
HIOS Plan ID: 11177NY0160002
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,000
$6,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement
Membership

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070001
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: GoldPlus-G2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$40 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$25 copayment
$25 copayment
$25 copayment
$25 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: GoldPlus-G2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0170002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
Inpatient Services
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$40 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$25 copayment
$25 copayment
$25 copayment
$25 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: PlatinumPlus-P2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0180001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance

$30 copayment

$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: PlatinumPlus-P2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0180002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

$100 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0190001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0210001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0210001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0210001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0210001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0230001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0250001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0200001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0220001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0220001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0220001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0220001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0240001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: NS-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0260001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1270001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical) $100 (Drug)

$0 (Medical) $300 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$30 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
$500 copayment
$200 copayment
$30 copayment
$200 copayment
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical) $100 (Drug)

$0 (Medical) $300 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$30 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
$500 copayment
$200 copayment
$30 copayment
$200 copayment
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1290001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$30 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
$500 copayment
$200 copayment
$30 copayment
$200 copayment
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1300001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$30 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
$500 copayment
$200 copayment
$30 copayment
$200 copayment
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement
Membership

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1310001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000 (Medical) $100 (Drug)

$2,000 (Medical) $300 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,000
$6,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
$30 copayment

$40 copayment

$50 copayment

$40 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1320001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000 (Medical) $100 (Drug)

$2,000 (Medical) $300 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,000
$6,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
$30 copayment

$40 copayment

$50 copayment

$40 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1330001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000 (Medical) $0 (Drug)

$2,000 (Medical) $0 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,000
$6,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
$30 copayment

$40 copayment

$50 copayment

$40 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1340001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000 (Medical) $0 (Drug)

$2,000 (Medical) $0 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,000
$6,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
$30 copayment

$40 copayment

$50 copayment

$40 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1350001-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$4,000 (Medical) $100 (Drug)

$8,000 (Medical) $300 (Drug)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,600
$13,200
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$40 copayment
$40 copayment
$40 copayment
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1350001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,400 (Medical) $100 (Drug)

$6,800 (Medical) $300 (Drug)

$5,200
$10,400
$30 copayment
$50 copayment

$5,200
$10,400
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$40 copayment
$40 copayment
$40 copayment
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1350001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$500 (Medical) $0 (Drug)

$1,000 (Medical) $0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
20% coinsurance
$100 copayment
$35 copayment
20% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1350001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
20% coinsurance
$75 copayment
$20 copayment
20% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1360001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$4,000 (Medical) $100 (Drug)

$8,000 (Medical) $300 (Drug)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,600
$13,200
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$40 copayment
$40 copayment
$40 copayment
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1360001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,400 (Medical) $100 (Drug)

$6,800 (Medical) $300 (Drug)

$5,200
$10,400
$30 copayment
$50 copayment

$5,200
$10,400
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$40 copayment
$40 copayment
$40 copayment
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1360001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$500 (Medical) $0 (Drug)

$1,000 (Medical) $0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
20% coinsurance
$100 copayment
$35 copayment
20% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConenct Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1360001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
20% coinsurance
$75 copayment
$20 copayment
20% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1370001-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$4,000 (Medical) $0 (Drug)

$8,000 (Medical) $0 (Drug)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,600
$13,200
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$40 copayment
$40 copayment
$40 copayment
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1370001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,400 (Medical) $0 (Drug)

$6,800 (Medical) $0 (Drug)

$5,200
$10,400
$30 copayment
$50 copayment

$5,200
$10,400
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$40 copayment
$40 copayment
$40 copayment
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1370001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$500 (Medical) $0 (Drug)

$1,000 (Medical) $0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
20% coinsurance
$100 copayment
$35 copayment
20% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1370001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
20% coinsurance
$75 copayment
$20 copayment
20% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1380001-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$4,000 (Medical) $0 (Drug)

$8,000 (Medical) $0 (Drug)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,600
$13,200
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$40 copayment
$40 copayment
$40 copayment
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1380001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,400 (Medical) $0 (Drug)

$6,800 (Medical) $0 (Drug)

$5,200
$10,400
$30 copayment
$50 copayment

$5,200
$10,400
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$40 copayment
$40 copayment
$40 copayment
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1380001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$500 (Medical) $0 (Drug)

$1,000 (Medical) $0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
20% coinsurance
$100 copayment
$35 copayment
20% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1380001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
20% coinsurance
$75 copayment
$20 copayment
20% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Bronze NS INN Pediatric Dental Dep 25 Acupuncture
HIOS Plan ID: 82483NY1910001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,400
$6,800

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
30% coinsurance
30% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$15 copayment
$35 copayment
$75 copayment
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Bronze NS INN Pediatric Dental Dep 29 Acupuncture
HIOS Plan ID: 82483NY1920001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,400
$6,800

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
30% coinsurance
30% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$15 copayment
$35 copayment
$75 copayment
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Oscar Insurance

Product Name: Oscar Bronze ST INN Dep25
HIOS Plan ID: 74289NY0080001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep25
HIOS Plan ID: 74289NY0050001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep25
HIOS Plan ID: 74289NY0050001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep25
HIOS Plan ID: 74289NY0050001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep25
HIOS Plan ID: 74289NY0050001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Gold ST INN Dep25
HIOS Plan ID: 74289NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Platinum ST INN Dep25
HIOS Plan ID: 74289NY0010001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Bronze ST INN Dep29
HIOS Plan ID: 74289NY0080002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep29
HIOS Plan ID: 74289NY0050002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep29
HIOS Plan ID: 74289NY0050002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep29
HIOS Plan ID: 74289NY0050002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep29
HIOS Plan ID: 74289NY0050002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Gold ST INN Dep29
HIOS Plan ID: 74289NY0030002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Platinum ST INN Dep29
HIOS Plan ID: 74289NY0010002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Platinum NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0020001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$150 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Platinum NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0020002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$150 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Gold NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0040001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment (after free visit
limit is reached)
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Gold NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0040002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment (after free visit
limit is reached)
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,000
$10,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,100
$12,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,700
$5,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$350
$700

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,300
$4,600
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$20 copayment
$150 copayment
$250 copayment
$125 copayment
$50 copayment
10% copayment
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$75 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,500
$3,000
$10 copayment (after free visit
limit is reached)
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$15 copayment
$130 copayment
$100 copayment
$100 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$10 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$25 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,000
$10,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,100
$12,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,700
$5,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$350
$700

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,300
$4,600
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$20 copayment
$150 copayment
$250 copayment
$125 copayment
$50 copayment
10% copayment
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$75 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,500
$3,000
$10 copayment (after free visit
limit is reached)
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$15 copayment
$130 copayment
$100 copayment
$100 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$10 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$25 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,600
$11,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$2,000 copayment
$250 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$30 copayment
$30 copayment

Additional Non-Standard Benefits: Free Generic Drugs

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,950
$9,900
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$2,000 copayment
$250 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$275
$550

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,550
$5,100
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$20 copayment
$150 copayment
$250 copayment
$125 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$75 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,200
$2,400
$10 copayment (after free visit
limit is reached)
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$15 copayment
$130 copayment
$100 copayment
$100 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$10 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$25 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,600
$11,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$2,000 copayment
$250 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,950
$9,900
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$2000 copayment
$250 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$275
$550

$2,000
$4,000
$15 copayment

$2,550
$5,100
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services

$35 copayment
$0 copayment

Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$20 copayment
$150 copayment
$250 copayment
$325 copayment (maternity)
$125 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$75 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

$9 copayment
$20 copayment
$40 copayment
$250 copayment

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment

$1,200
$2,400
$10 copayment (after free visit
limit is reached)
$20 copayment
$0 copayment

Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services

$20 copayment
$0 copayment

Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$15 copayment
$130 copayment
$100 copayment
$125 copayment (maternity)
$100 copayment
$30 copayment
5% copayment
$15 copayment

$35 copayment

$10 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$25 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

$6 copayment
$15 copayment
$30 copayment
$100 copayment

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Bronze NS INN Dep25 Free PCP Visits Wellness
HIOS Plan ID: 74289NY0090001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance

$6,600
$13,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services

50% coinsurance
0% coinsurance

Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$35 copayment
$150 copayment
$1500 copayment
$1600 copayment (maternity)
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

50% coinsurance

$30 copayment

50% coinsurance

$50 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

$10 copayment
$35 copayment
$70 copayment
50% coinsurance

Additional Non-Standard Benefits: Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Bronze NS INN Dep29 Free PCP Visits Wellness
HIOS Plan ID: 74289NY0090002
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance

$6,600
$13,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services

50% coinsurance
0% coinsurance

Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$35 copayment
$150 copayment
$1500 copayment
$1600 copayment (maternity)
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

50% coinsurance

$30 copayment

50% coinsurance

$50 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

$10 copayment
$35 copayment
$70 copayment
50% coinsurance

Additional Non-Standard Benefits: Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Bronze NS INN Dep25 Free PCP Visits Wellness
HIOS Plan ID: 74289NY0100001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

50% coinsurance

$0 copayment

50% coinsurance

$0 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Bronze NS INN Dep29 Free PCP Visits Wellness
HIOS Plan ID: 74289NY0100002
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

50% coinsurance

$0 copayment

50% coinsurance

$0 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 1000 Platinum NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0410001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$1,000
$2,000

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 1000 Platinum NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0410002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$1,000
$2,000

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 4500 Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0500001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$4,500
$9,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 4500 Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0500001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,500
$7,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,500
$7,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 4500 Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0500001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,200
$2,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,200
$2,400
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 4500 Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0500001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$500
$1,000

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,200
$2,400
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 6600 Bronze NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0520001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

50% coinsurance

$0 copayment

50% coinsurance

$0 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 6600 Bronze NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0520002
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

50% coinsurance

$0 copayment

50% coinsurance

$0 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 2000 Gold NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0540001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$2000
$4,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$40 copayment

$0 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 2000 Gold NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0540002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$2000
$4,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$40 copayment

$0 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs and Free PCP Visits Available

Plan Name: United Healthcare

Product Name: United Healthcare Compass Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010013
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010014
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010005
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010007
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010010
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
30% coinsurance
30% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

$50 copayment

30% coinsurance

$50 copayment

30% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400

$4,000
$8,000

$30 copayment
$50 copayment
$0 copayment

$30 copayment
$40 copayment
$0

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$55 copayment
30% coinsurance
30% coinsurance
$40 copayment
25% coinsurance
$30 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$175
$350

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$15 copayment
$30 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$25 copayment
$45 copayment
$250 copayment
$75 copayment
$30 copayment
10% coinsurance
$20 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$975
$1950
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$35 copayment
$100 copayment
$75 copayment
$20 copayment
5% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
30% coinsurance
30% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

$50 copayment

30% coinsurance

$50 copayment

30% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$30 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$55 copayment
30% coinsurance
30% coinsurance
$40 copayment
25% coinsurance
$30 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$175
$350

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$15 copayment
$30 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$25 copayment
$45 copayment
$250 copayment
$75 copayment
$30 copayment
10% coinsurance
$20 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$35 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$975
$1,950
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance

$6 copayment
$15 copayment
$35 copayment
$100 copayment
$75 copayment
$20 copayment
5% coinsurance

$15 copayment

$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Broome County
Individual Market Products

Plan

Standard

Non-Standard

Capital District Physicians Health Plan

(CDPHP)

Emblem Health

Excellus

Fidelis

MVP

Univera

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep25
HIOS Plan ID: 88582NY0170001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep25
HIOS Plan ID: 88582NY0150001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Platinum Platinum ST INN Dep25
HIOS Plan ID: 88582NY0140001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep29
HIOS Plan ID: 88582NY020001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep29
HIOS Plan ID: 88582NY0260001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0290001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep29 Acupuncture Home Health Care
Three PCP visits are covered in full Wellness
HIOS Plan ID: 56184NY0150008-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$200 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$200 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150010
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical) $100 (Drug)

$1,700 (Medical) $200 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep29 Acupuncture Home Health
Care Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150011
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep29 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep29 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150014-01
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep25 Acupuncture Home Health

Care Three PCP visits are covered in full Wellness

HIOS Plan ID: 56184NY0150015-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$675
$1,350

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep25 Acupuncture Home Health Care

Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150018
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical)
$1,700 (Medical)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep25 Acupuncture Home

Health Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150019
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep25 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150020
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep25 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Cattaraugus County
Individual Market Products

Plan

Standard

Non-Standard

BlueCross BlueShield of Western NY

Fidelis

Health Republic

Independent Health

Plan Name: BlueCross BlueShield of Western NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 49526NY0450001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 49526NY0450026
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 49526NY0450002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 49526NY0450027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 49526NY0450036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Value, Bronze, NS, INN, Dep25
HIOS Plan ID: 49526NY0450006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Value, Bronze, NS, INN, Dep29
HIOS Plan ID: 49526NY0450007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$5 copayment
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS 8100EX, Bronze, NS, OON, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450008
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS 8100EX, Bronze, NS, OON, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450009
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,300
$2,600

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,00
$4,000
$15 copayment
$25 copayment
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$20 copayment
30% coinsurance
$250 copayment
$100 copayment
$55 copayment
50% coinsurance
$15 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

$15 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$3 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$35 copayment
50% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,300
$2,600

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,00
$4,000
$15 copayment
$25 copayment
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$20 copayment
30% coinsurance
$250 copayment
$100 copayment
$55 copayment
50% coinsurance
$15 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

$15 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,00
$2,000
$10 copayment
$20 copayment
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$3 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$35 copayment
50% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Aqua, Gold, NS, OON, Dep25
HIOS Plan ID: 49526NY0450031
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$50 copayment
$50 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Aqua, Gold, NS, OON, Dep29
HIOS Plan ID: 49526NY0450032
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$50 copayment
$50 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS110, Platinum, NS, OON, Dep25
HIOS Plan ID: 49526NY0450040
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$20 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$20 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$30 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS110, Platinum, NS, OON, Dep29
HIOS Plan ID: 49526NY0450041
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$20 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$20 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$30 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
$250 Wellness Card

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Independent Health

Product Name: Standard Bronze ST OON Dep25
HIOS Plan ID: 18029NY1310009
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Gold ST OON Dep25
HIOS Plan ID: 18029NY1220001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Platinum ST OON Dep25
HIOS Plan ID: 18029NY1180001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Bronze ST OON Dep29
HIOS Plan ID: 18029NY1310010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Gold ST OON Dep29
HIOS Plan ID: 18029NY1220002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Platinum ST OON Dep29
HIOS Plan ID: 18029NY1180002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Max Bronze NS INN Dep25 Adult Vision Nurse Helpline Telemedicine Wellness
HIOS Plan ID: 18029NY1360069
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$40 copayment
25% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
50% coinsurance
50% coinsurance
25% coinsurance
25% coinsurance
$75 copayment
50% coinsurance
25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

25% coinsurance
$40 copayment
25% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: Max Bronze NS INN Dep29 Adult Vision Nurse Helpline Telemedicine Wellness
HIOS Plan ID: 18029NY1360070
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$40 copayment
25% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
50% coinsurance
50% coinsurance
25% coinsurance
25% coinsurance
$75 copayment
50% coinsurance
25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

25% coinsurance
$40 copayment
25% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$4 copayment
$30 copayment
50% copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
10% coinsurance
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
50% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$4 copayment
$30 copayment
50% copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
10% coinsurance
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
50% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Gold NS OON Dep25 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220021
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$45 copayment

$35 copayment

$25 copayment

$35 copayment

$45 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$45 copayment
$15 copayment
$45 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Gold NS OON Dep29 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220022
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$45 copayment

$35 copayment

$25 copayment

$35 copayment

$45 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$45 copayment
$15 copayment
$45 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: FlexFit Platinum NS OON Dep25 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180021
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$10 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: FlexFit Platinum NS OON Dep29 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180022
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$10 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Univera Healthcare

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0950004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0940004
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0930004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0950002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0940002
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0930002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0950012
Metal Level: Bronze
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
$ copayment

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Not covered
50% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0950014
Metal Level: Bronze
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Not covered
50% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008
Metal Level: Silver
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$15 copayment
$15 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$ copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance

$10 copayment
$10 copayment
Gym Membership
Reimbursement

Not covered
5% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010
Metal Level: Silver
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$ copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligibile

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$ copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$15 copayment
$15 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$ copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance

$10 copayment
$10 copayment
Gym Membership
Reimbursement

Not covered
5% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligibile

Plan Name: Univera

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0940014
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment

$0 copayment

$30 copayment
$30 copayment

$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0940016
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0930008
Metal Level: Platinum
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Univera

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0930010
Metal Level: Platinum
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$25 copayment
Gym Membership
Reimbursement

Cayuga County
Individual Market Products

Plan

Standard

Non-Standard

Excellus

Fidelis

Health Republic

MVP

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep29 Acupuncture Home Health Care
Three PCP visits are covered in full Wellness
HIOS Plan ID: 56184NY0150008-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$200 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$200 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150010
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical) $100 (Drug)

$1,700 (Medical) $200 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep29 Acupuncture Home Health
Care Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150011
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep29 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep29 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150014-01
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep25 Acupuncture Home Health

Care Three PCP visits are covered in full Wellness

HIOS Plan ID: 56184NY0150015-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$675
$1,350

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep25 Acupuncture Home Health Care

Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150018
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical)
$1,700 (Medical)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep25 Acupuncture Home

Health Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150019
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep25 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150020
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep25 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Chautauqua County
Individual Market Products

Plan

Standard

Non-Standard

BlueCross BlueShield of Western NY

Fidelis

Health Republic

Independent Health

Univera

Plan Name: BlueCross BlueShield of Western NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 49526NY0450001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 49526NY0450026
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 49526NY0450002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 49526NY0450027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 49526NY0450036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Value, Bronze, NS, INN, Dep25
HIOS Plan ID: 49526NY0450006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Cad

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Value, Bronze, NS, INN, Dep29
HIOS Plan ID: 49526NY0450007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$5 copayment
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS 8100EX, Bronze, NS, OON, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450008
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS 8100EX, Bronze, NS, OON, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450009
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,300
$2,600

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,00
$4,000
$15 copayment
$25 copayment
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$20 copayment
30% coinsurance
$250 copayment
$100 copayment
$55 copayment
50% coinsurance
$15 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

$15 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$3 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$35 copayment
50% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,300
$2,600

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,00
$4,000
$15 copayment
$25 copayment
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$20 copayment
30% coinsurance
$250 copayment
$100 copayment
$55 copayment
50% coinsurance
$15 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

$15 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,00
$2,000
$10 copayment
$20 copayment
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$3 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$35 copayment
50% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Aqua, Gold, NS, OON, Dep25
HIOS Plan ID: 49526NY0450031
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$50 copayment
$50 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Aqua, Gold, NS, OON, Dep29
HIOS Plan ID: 49526NY0450032
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$50 copayment
$50 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS110, Platinum, NS, OON, Dep25
HIOS Plan ID: 49526NY0450040
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$20 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$20 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$30 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS110, Platinum, NS, OON, Dep29
HIOS Plan ID: 49526NY0450041
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$20 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$20 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$30 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
$250 Wellness Card

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Independent Health

Product Name: Standard Bronze ST OON Dep25
HIOS Plan ID: 18029NY1310009
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Gold ST OON Dep25
HIOS Plan ID: 18029NY1220001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Platinum ST OON Dep25
HIOS Plan ID: 18029NY1180001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Bronze ST OON Dep29
HIOS Plan ID: 18029NY1310010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Gold ST OON Dep29
HIOS Plan ID: 18029NY1220002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Platinum ST OON Dep29
HIOS Plan ID: 18029NY1180002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Max Bronze NS INN Dep25 Adult Vision Nurse Helpline Telemedicine Wellness
HIOS Plan ID: 18029NY1360069
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$40 copayment
25% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
50% coinsurance
50% coinsurance
25% coinsurance
25% coinsurance
$75 copayment
50% coinsurance
25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

25% coinsurance
$40 copayment
25% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: Max Bronze NS INN Dep29 Adult Vision Nurse Helpline Telemedicine Wellness
HIOS Plan ID: 18029NY1360070
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$40 copayment
25% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
50% coinsurance
50% coinsurance
25% coinsurance
25% coinsurance
$75 copayment
50% coinsurance
25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

25% coinsurance
$40 copayment
25% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$4 copayment
$30 copayment
50% copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
10% coinsurance
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
50% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$4 copayment
$30 copayment
50% copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
10% coinsurance
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
50% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Gold NS OON Dep25 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220021
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$45 copayment

$35 copayment

$25 copayment

$35 copayment

$45 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$45 copayment
$15 copayment
$45 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Gold NS OON Dep29 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220022
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$45 copayment

$35 copayment

$25 copayment

$35 copayment

$45 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$45 copayment
$15 copayment
$45 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: FlexFit Platinum NS OON Dep25 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180021
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$10 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: FlexFit Platinum NS OON Dep29 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180022
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$10 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Univera Healthcare

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0950004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0940004
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0930004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0950002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0940002
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0930002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0950012
Metal Level: Bronze
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
$ copayment

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Not covered
50% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0950014
Metal Level: Bronze
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Not covered
50% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008
Metal Level: Silver
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$15 copayment
$15 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$ copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance

$10 copayment
$10 copayment
Gym Membership
Reimbursement

Not covered
5% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010
Metal Level: Silver
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$ copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$ copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$15 copayment
$15 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$ copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance

$10 copayment
$10 copayment
Gym Membership
Reimbursement

Not covered
5% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0940014
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment

$0 copayment

$30 copayment
$30 copayment

$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0940016
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0930008
Metal Level: Platinum
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Univera

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0930010
Metal Level: Platinum
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$25 copayment
Gym Membership
Reimbursement

Chemung County
Individual Market Products

Plan

Standard

Non-Standard

Excellus

Fidelis

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Chenango County
Individual Market Products

Plan

Standard

Non-Standard

Capital District Physicians Health Plan

(CDPHP)

Excellus

Fidelis

MVP

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement and
Wellness Discounts for Youth Sports, and
Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement and Wellness
Discounts for Youth Sports, and Other Wellness
Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement and
Wellness Discounts for Youth Sports, and
Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement and
Wellness Discounts for Youth
Sports, and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement and Wellness
Discounts for Youth Sports, and
Other Wellness Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep29 Acupuncture Home Health Care
Three PCP visits are covered in full Wellness
HIOS Plan ID: 56184NY0150008-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$200 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$200 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150010
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical) $100 (Drug)

$1,700 (Medical) $200 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep29 Acupuncture Home Health
Care Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150011
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep29 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep29 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150014-01
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep25 Acupuncture Home Health

Care Three PCP visits are covered in full Wellness

HIOS Plan ID: 56184NY0150015-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$675
$1,350

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep25 Acupuncture Home Health Care

Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150018
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical)
$1,700 (Medical)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep25 Acupuncture Home

Health Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150019
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep25 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150020
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep25 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Clinton County
Individual Market Products

Plan

Standard

Non-Standard

Blue Shield of NENY

Empire Blue Cross

Excellus

MVP

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 36346NY0480001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 36346NY0480026
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep25
HIOS Plan ID: 36346NY0480035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 36346NY0480002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 36346NY0480027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 36346NY0480036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: Empire Blue Cross

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160011
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160013
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160017
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160029
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160003
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160005
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1,000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1,000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Health Savings Account (HSA):
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Health Savings Account (HSA):
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160103
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160105
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160111
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description

Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160113
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 1000, Gold, NS, INN, Pediatric Dental, Dep 25, a MultiState Plan
HIOS Plan ID: 80519NY0330006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligibile

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 1000, Gold, NS, INN, Pediatric Dental, Dep 29, a MultiState Plan
HIOS Plan ID: 80519NY0330014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Columbia County
Individual Market Products

Plan

Standard

Non-Standard

Blue Shield of NENY

Capital District Physicians Health Plan

(CDPHP)

Emblem Health

Empire Blue Cross Blue Shield

Fidelis

Health Republic

MVP

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 36346NY0480001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 36346NY0480026
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep25
HIOS Plan ID: 36346NY0480035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 36346NY0480002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 36346NY0480027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 36346NY0480036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep25
HIOS Plan ID: 88582NY0170001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep25
HIOS Plan ID: 88582NY0150001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Platinum Platinum ST INN Dep25
HIOS Plan ID: 88582NY0140001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep29
HIOS Plan ID: 88582NY020001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep29
HIOS Plan ID: 88582NY0260001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0290001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160012
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160014
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160018
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160028
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160030
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160020
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160022
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160107
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160109
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160115
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160117
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330005
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep29 Acupuncture Home Health Care
Three PCP visits are covered in full Wellness
HIOS Plan ID: 56184NY0150008-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$200 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$200 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150010
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical) $100 (Drug)

$1,700 (Medical) $200 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep29 Acupuncture Home Health
Care Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150011
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep29 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep29 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150014-01
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep25 Acupuncture Home Health

Care Three PCP visits are covered in full Wellness

HIOS Plan ID: 56184NY0150015-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$675
$1,350

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep25 Acupuncture Home Health Care

Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150018
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical)
$1,700 (Medical)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep25 Acupuncture Home

Health Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150019
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep25 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150020
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep25 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Cortland County
Individual Market Products

Plan

Standard

Non-Standard

Excellus

Fidelis

MVP

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Health Care

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep29 Acupuncture Home Health Care
Three PCP visits are covered in full Wellness
HIOS Plan ID: 56184NY0150008-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$200 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$200 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150010
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical) $100 (Drug)

$1,700 (Medical) $200 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep29 Acupuncture Home Health
Care Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150011
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep29 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep29 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150014-01
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep25 Acupuncture Home Health

Care Three PCP visits are covered in full Wellness

HIOS Plan ID: 56184NY0150015-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$675
$1,350

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep25 Acupuncture Home Health Care

Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150018
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical)
$1,700 (Medical)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep25 Acupuncture Home

Health Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150019
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep25 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150020
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep25 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Delaware County
Individual Market Products

Plan

Standard

Non-Standard

Capital District Physicians Health Plan

(CDPHP)

Emblem Health

Empire Blue Cross Blue Shield

Excellus

Fidelis

Health Republic

MVP

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep25
HIOS Plan ID: 88582NY0170001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep25
HIOS Plan ID: 88582NY0150001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Platinum Platinum ST INN Dep25
HIOS Plan ID: 88582NY0140001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep29
HIOS Plan ID: 88582NY020001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep29
HIOS Plan ID: 88582NY0260001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0290001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160012
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160014
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160018
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160028
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160030
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160020
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160022
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160107
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160109
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160115
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160117
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligile

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330005
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Elgible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bassett Preferred Silver Silver NS INN Dep29
HIOS Plan ID: 78124NY0920006
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,250
$2,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1250 copayment
$250 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$30 copayment
$50 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bassett Preferred Silver Silver NS INN Dep29
HIOS Plan ID: 78124NY0920006-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,250
$2,500

$5,200
$10,400
$30 copayment
$50 copayment

$4,250
$8,500
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,250 copayment
$250 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$30 copayment
$50 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bassett Preferred Silver Silver NS INN Dep29
HIOS Plan ID: 78124NY0920006-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$250 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bassett Preferred Silver Silver NS INN Dep29
HIOS Plan ID: 78124NY0920006-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,000
$4,000
$5 copayment
$10 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$25 copayment
$50 copayment
$50 copayment
$100 copayment
$25 copayment
$10 copayment
50% coinsurance
$10 copayment

$35 copayment

$5 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
$5 copayment
$10 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bassett Preferred Silver Silver NS INN Dep25
HIOS Plan ID: 78124NY0920008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,250
$2,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,250 copayment
$250 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$30 copayment
$50 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bassett Preferred Silver Silver NS INN Dep25
HIOS Plan ID: 78124NY0920008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,250
$2,500

$5,200
$10,400
$30 copayment
$50 copayment

$4,250
$8,500
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,250 copayment
$250 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$30 copayment
$50 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bassett Preferred Silver Silver NS INN Dep25
HIOS Plan ID: 78124NY0920008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$250 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bassett Preferred Silver Silver NS INN Dep25
HIOS Plan ID: 78124NY0920008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,000
$4,000
$5 copayment
$10 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$25 copayment
$50 copayment
$100 copayment
$25 copayment
$10 copayment
50% coinsurance
$10 copayment

$35 copayment

$5 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
$5 copayment
$10 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bassett Preferred Gold Gold NS INN Dep29
HIOS Plan ID: 78124NY0920002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$4,000
$8,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bassett Preferred Gold Gold NS INN Dep25
HIOS Plan ID: 78124NY0920004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$4,000
$8,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Dutchess County
Individual Market Products

Plan

Standard

Non-Standard

Capital District Physicians Health Plan

(CDPHP)

Emblem Health

Empire Blue Cross Blue Shield

Fidelis

Health Republic

MVP Health Care

United Healthcare

Wellcare

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts
for Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts
for Youth Sports and Other Wellness Service

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Service

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep25
HIOS Plan ID: 88582NY0170001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep25
HIOS Plan ID: 88582NY0150001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Platinum Platinum ST INN Dep25
HIOS Plan ID: 88582NY0140001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep29
HIOS Plan ID: 88582NY020001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep29
HIOS Plan ID: 88582NY0260001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0290001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160012
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160014
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160018
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160028
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160030
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160020
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160022
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160107
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160109
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160115
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160117
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330005
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep29 Acupuncture Home Health Care
Three PCP visits are covered in full Wellness
HIOS Plan ID: 56184NY0150008-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$200 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$200 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150010
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical) $100 (Drug)

$1,700 (Medical) $200 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep29 Acupuncture Home Health
Care Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150011
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep29 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep29 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150014-01
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep25 Acupuncture Home Health

Care Three PCP visits are covered in full Wellness

HIOS Plan ID: 56184NY0150015-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$675
$1,350

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep25 Acupuncture Home Health Care

Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150018
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical)
$1,700 (Medical)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep25 Acupuncture Home

Health Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150019
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep25 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150020
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep25 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: United Healthcare

Product Name: United Healthcare Compass Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010013
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010014
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010005
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010007
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010010
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
30% coinsurance
30% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

$50 copayment

30% coinsurance

$50 copayment

30% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400

$4,000
$8,000

$30 copayment
$50 copayment
$0 copayment

$30 copayment
$40 copayment
$0

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$55 copayment
30% coinsurance
30% coinsurance
$40 copayment
25% coinsurance
$30 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$175
$350

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$15 copayment
$30 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$25 copayment
$45 copayment
$250 copayment
$75 copayment
$30 copayment
10% coinsurance
$20 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$975
$1950
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$35 copayment
$100 copayment
$75 copayment
$20 copayment
5% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
30% coinsurance
30% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

$50 copayment

30% coinsurance

$50 copayment

30% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$30 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$55 copayment
30% coinsurance
30% coinsurance
$40 copayment
25% coinsurance
$30 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

30% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$175
$350

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$15 copayment
$30 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$25 copayment
$45 copayment
$250 copayment
$75 copayment
$30 copayment
10% coinsurance
$20 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$35 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$975
$1,950
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance

$6 copayment
$15 copayment
$35 copayment
$100 copayment
$75 copayment
$20 copayment
5% coinsurance

$15 copayment

$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Erie County
Individual Market Products

Plan

Standard

Non-Standard

BlueCross BlueShield of Western NY

Fidelis

Health Republic

Independent Health

Univera Healthcare

Plan Name: BlueCross BlueShield of Western NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 49526NY0450001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 49526NY0450026
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 49526NY0450002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 49526NY0450027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 49526NY0450036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Value, Bronze, NS, INN, Dep25
HIOS Plan ID: 49526NY0450006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Value, Bronze, NS, INN, Dep29
HIOS Plan ID: 49526NY0450007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$5 copayment
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS 8100EX, Bronze, NS, OON, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450008
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS 8100EX, Bronze, NS, OON, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450009
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 2000, Silver, NS, INN, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
$5 copayment
35% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
50% coinsurance
50% coinsurance
35% coinsurance
20% coinsurance
$70 copayment
50% coinsurance
$5 copayment

$50 copayment

$0 copayment

$50 copayment

35% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

35% coinsurance
35% coinsurance
35% coinsurance
Not covered
35% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 2000, Silver, NS, INN, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450017-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,500
$3,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
30% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
50% coinsurance
50% coinsurance
30% coinsurance
15% coinsurance
$70 copayment
50% coinsurance
$5 copayment

$50 copayment

$0 copayment

$50 copayment

30% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

30% coinsurance
30% coinsurance
30% coinsurance
Not covered
30% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 2000, Silver, NS, INN, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450017-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,725
$3,450
$5 copayment
10% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
20% coinsurance
20% coinsurance
10% coinsurance
10% coinsurance
$50 copayment
50% coinsurance
$5 copayment

$35 copayment

$0 copayment

$35 copayment

10% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
10% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 2000, Silver, NS, INN, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450017-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,500
$3,000
$5 copayment
8% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
20% coinsurance
20% coinsurance
8% coinsurance
8% coinsurance
$30 copayment
50% coinsurance
$5 copayment

$35 copayment

$0 copayment

$35 copayment

8% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

8% coinsurance
8% coinsurance
8% coinsurance
Not covered
8% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 2000, Silver, NS, INN, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450018
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
$5 copayment
35% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
50% coinsurance
50% coinsurance
35% coinsurance
20% coinsurance
$70 copayment
50% coinsurance
$5 copayment

$50 copayment

$0 copayment

$50 copayment

35% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

35% coinsurance
35% coinsurance
35% coinsurance
Not covered
35% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 2000, Silver, NS, INN, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450018-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,500
$3,000

$5,200
$10,400
$30 copayment
$50 copayment

$5,200
$10,400
$5 copayment
30% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
50% coinsurance
50% coinsurance
30% coinsurance
15% coinsurance
$70 copayment
50% coinsurance
$5 copayment

$50 copayment

$0 copayment

$50 copayment

30% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

30% coinsurance
30% coinsurance
30% coinsurance
Not covered
30% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 2000, Silver, NS, INN, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450018-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,725
$3,450
$5 copayment
10% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
20% coinsurance
20% coinsurance
10% coinsurance
10% coinsurance
$50 copayment
50% coinsurance
$5 copayment

$35 copayment

$0 copayment

$35 copayment

10% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
10% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 2000, Silver, NS, INN, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450018-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,500
$3,000
$5 copayment
8% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
20% coinsurance
20% coinsurance
8% coinsurance
8% coinsurance
$30 copayment
50% coinsurance
$5 copayment

$35 copayment

$0 copayment

$35 copayment

8% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

8% coinsurance
8% coinsurance
8% coinsurance
Not covered
8% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,300
$2,600

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,00
$4,000
$15 copayment
$25 copayment
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$20 copayment
30% coinsurance
$250 copayment
$100 copayment
$55 copayment
50% coinsurance
$15 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

$15 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$3 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$35 copayment
50% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,300
$2,600

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,00
$4,000
$15 copayment
$25 copayment
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$20 copayment
30% coinsurance
$250 copayment
$100 copayment
$55 copayment
50% coinsurance
$15 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

$15 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,00
$2,000
$10 copayment
$20 copayment
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$3 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$35 copayment
50% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 850, Gold, NS, INN, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450029
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850
$1,700

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
15% coinsurance
15% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
30% coinsurance
30% coinsurance
15% coinsurance
15% coinsurance
$60 copayment
50% coinsurance
15% coinsurance

$40 copayment

15% coinsurance

$40 copayment

15% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

15% coinsurance
15% coinsurance
15% coinsurance
Not covered
15% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 850, Gold, NS, INN, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450030
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850
$1,700

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
15% coinsurance
15% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
30% coinsurance
30% coinsurance
15% coinsurance
15% coinsurance
$60 copayment
50% coinsurance
15% coinsurance

$40 copayment

$0 copayment

$40 copayment

15% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

15% coinsurance
15% coinsurance
15% coinsurance
Not covered
15% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Aqua, Gold, NS, OON, Dep25
HIOS Plan ID: 49526NY0450031
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$50 copayment
$50 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Aqua, Gold, NS, OON, Dep29
HIOS Plan ID: 49526NY0450032
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$50 copayment
$50 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 250, Platinum, NS, INN, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450038
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
8% coinsurance
8% coinsurance
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$2 copayment
20% coinsurance
20% coinsurance
8% coinsurance
8% coinsurance
$55 copayment
50% coinsurance
8% coinsurance

$35 copayment

$0 copayment

$35 copayment

8% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

8% coinsurance
8% coinsurance
8% coinsurance
Not covered
8% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: 250, Platinum, NS, INN, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450039
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
8% coinsurance
8% coinsurance
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$2 copayment
20% coinsurance
20% coinsurance
8% coinsurance
8% coinsurance
$55 copayment
50% coinsurance
8% coinsurance

$35 copayment

$0 copayment

$35 copayment

8% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

8% coinsurance
8% coinsurance
8% coinsurance
Not covered
8% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS110, Platinum, NS, OON, Dep25
HIOS Plan ID: 49526NY0450040
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$20 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$20 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$30 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS110, Platinum, NS, OON, Dep29
HIOS Plan ID: 49526NY0450041
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$20 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$20 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$30 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
$250 Wellness Card

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
$0 copayment

Additional Non-Standard Benefits: Acupuncture, Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Independent Health

Product Name: Standard Bronze ST OON Dep25
HIOS Plan ID: 18029NY1310009
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Gold ST OON Dep25
HIOS Plan ID: 18029NY1220001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Platinum ST OON Dep25
HIOS Plan ID: 18029NY1180001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Bronze ST OON Dep29
HIOS Plan ID: 18029NY1310010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Gold ST OON Dep29
HIOS Plan ID: 18029NY1220002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Platinum ST OON Dep29
HIOS Plan ID: 18029NY1180002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Choice Plus Bronze NS OON Dep25 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1310025
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500
$7,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
30% coinsurance
30% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
50% coinsurance
30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

30% coinsurance
30% coinsurance
30% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: Choice Plus Bronze NS OON Dep29 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1310026
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500
$7,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
30% coinsurance
30% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
50% coinsurance
30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

30% coinsurance
30% coinsurance
30% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: Max Bronze NS INN Dep25 Adult Vision Nurse Helpline Telemedicine Wellness
HIOS Plan ID: 18029NY1360069
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$40 copayment
25% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
50% coinsurance
50% coinsurance
25% coinsurance
25% coinsurance
$75 copayment
50% coinsurance
25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

25% coinsurance
$40 copayment
25% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: Max Bronze NS INN Dep29 Adult Vision Nurse Helpline Telemedicine Wellness
HIOS Plan ID: 18029NY1360070
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$40 copayment
25% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
50% coinsurance
50% coinsurance
25% coinsurance
25% coinsurance
$75 copayment
50% coinsurance
25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

25% coinsurance
$40 copayment
25% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$4 copayment
$30 copayment
50% copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
10% coinsurance
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
50% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$4 copayment
$30 copayment
50% copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
10% coinsurance
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
50% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Gold NS OON Dep25 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220021
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$45 copayment

$35 copayment

$25 copayment

$35 copayment

$45 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$45 copayment
$15 copayment
$45 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Gold NS OON Dep29 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220022
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$45 copayment

$35 copayment

$25 copayment

$35 copayment

$45 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$45 copayment
$15 copayment
$45 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: Choice Plus Gold NS OON Dep25 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220025
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$1,000
$2,000

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,500
$11,000
$20 copayment
$40 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$40 copayment

$35 copayment

$20 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$40 copayment
$20 copayment
$40 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: Choice Plus Gold NS OON Dep29 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220026
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$1,000
$2,000

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,500
$11,000
$20 copayment
$40 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$40 copayment

$35 copayment

$20 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$40 copayment
$20 copayment
$40 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: FlexFit Platinum NS OON Dep25 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180021
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$10 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: FlexFit Platinum NS OON Dep29 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180022
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$10 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: Choice Plus Platinum NS OON Dep25 Adult Vision Nurse Helpline Telemedicine
WellnessHIOS Plan ID: 18029NY1180077
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: Choice Plus Platinum NS OON Dep29 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180078
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Univera Healthcare

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0950004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0940004
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0930004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0950002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0940002
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0930002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0950012
Metal Level: Bronze
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
$ copayment

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Not covered
50% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0950014
Metal Level: Bronze
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Not covered
50% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008
Metal Level: Silver
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$15 copayment
$15 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$ copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance

$10 copayment
$10 copayment
Gym Membership
Reimbursement

Not covered
5% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010
Metal Level: Silver
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$ copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$ copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$15 copayment
$15 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$ copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance

$10 copayment
$10 copayment
Gym Membership
Reimbursement

Not covered
5% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0940014
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment

$0 copayment

$30 copayment
$30 copayment

$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0940016
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera Healthcare

Product Name: Univera Preferred Gold Gold NS INN Dep29
Plan HIOS ID: 78124NY1140002
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000

$4,000
$8,000

$25 copayment
$40 copayment
$ copayment

$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment

$100 copayment
$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera Healthcare

Product Name: Univera Preferred Gold Gold NS INN Dep25
HIOS Plan ID: 78124NY1140004
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$500 copayment
$100 copayment
$40 copayment
20% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment

$100 copayment
$25 copayment
$40 copayment

$30 copayment
$30 copayment

Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0930008
Metal Level: Platinum
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0930010
Metal Level: Platinum
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$25 copayment
Gym Membership
Reimbursement

Essex County
Individual Market Products

Plan

Standard

Non-Standard

Blue Shield of NENY

Emblem Health

Empire Blue Cross Blue Shield

Excellus

Fidelis

Health Republic

MVP Health Care

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 36346NY0480001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 36346NY0480026
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep25
HIOS Plan ID: 36346NY0480035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 36346NY0480002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 36346NY0480027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 36346NY0480036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health

Pediatric Basic Dental Care

Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Empire Blue Cross

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160011
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160013
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160017
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160029
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160003
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160005
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1,000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1,000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Health Savings Account (HSA):
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Health Savings Account (HSA):
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160103
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160105
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160111
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160113
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 1000, Gold, NS, INN, Pediatric Dental, Dep 25, a MultiState Plan
HIOS Plan ID: 80519NY0330006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 1000, Gold, NS, INN, Pediatric Dental, Dep 29, a MultiState Plan
HIOS Plan ID: 80519NY0330014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
0% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9.000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
No covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
0% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9.000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
No covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupunctu

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Franklin County
Individual Market Products

Plan

Standard

Non-Standard

Excellus Blue Cross Blue Shield

Fidelis

MVP Health Care

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Fulton County
Individual Market Products

Plan

Standard

Non-Standard

Blue Shield of NENY

Capital District Physicians Health Plan

(CDPHP)

Emblem Health

Empire Blue Cross

Excellus Blue Cross Blue Shield

Fidelis

MVP Health Care

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 36346NY0480001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 36346NY0480026
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep25
HIOS Plan ID: 36346NY0480035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 36346NY0480002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 36346NY0480027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 36346NY0480036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness Discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness Discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep25
HIOS Plan ID: 88582NY0170001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep25
HIOS Plan ID: 88582NY0150001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Platinum Platinum ST INN Dep25
HIOS Plan ID: 88582NY0140001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep29
HIOS Plan ID: 88582NY020001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep29
HIOS Plan ID: 88582NY0260001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0290001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160007-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160011
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160013
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160017
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160023-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160029
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160003
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
0% coinsurance
20% coinsurance

Additional Non-Standard Benefits: Gym Membership Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160005
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1,000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1,000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160025-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Health Savings Account (HSA):
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160095-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Health Savings Account (HSA):
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160097-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160103
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160105
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160111
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160113
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330004-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 1000, Gold, NS, INN, Pediatric Dental, Dep 25, a MultiState Plan
HIOS Plan ID: 80519NY0330006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 2450 for HSA, Silver, NS, INN, Pediatric Dental, Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Multi State Plan

Product Name: Empire Blue Cross HMO 1000, Gold, NS, INN, Pediatric Dental, Dep 29, a MultiState Plan
HIOS Plan ID: 80519NY0330014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Genesee County
Individual Market Products

Plan

Standard

Non-Standard

BlueCross BlueShield of Western NY

Fidelis

Health Republic

Independent Health

MVP Health Care

Univera Healthcare

Plan Name: BlueCross BlueShield of Western NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 49526NY0450001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 49526NY0450026
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 49526NY0450035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 49526NY0450002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 49526NY0450015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 49526NY0450027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 49526NY0450036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Value, Bronze, NS, INN, Dep25
HIOS Plan ID: 49526NY0450006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Value, Bronze, NS, INN, Dep29
HIOS Plan ID: 49526NY0450007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$5 copayment
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance

0% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS 8100EX, Bronze, NS, OON, Dep25, tiered benefit
HIOS Plan ID: 49526NY0450008
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS 8100EX, Bronze, NS, OON, Dep29, tiered benefit
HIOS Plan ID: 49526NY0450009
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,300
$2,600

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,00
$4,000
$15 copayment
$25 copayment
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$20 copayment
30% coinsurance
$250 copayment
$100 copayment
$55 copayment
50% coinsurance
$15 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

$15 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep25
HIOS Plan ID: 49526NY0450019-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$3 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$35 copayment
50% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,300
$2,600

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$750 copayment
$150 copayment
$75 copayment
50% coinsurance
$25 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$40 copayment
$40 copayment
$40 copayment
Not covered
$40 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,00
$4,000
$15 copayment
$25 copayment
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$20 copayment
30% coinsurance
$250 copayment
$100 copayment
$55 copayment
50% coinsurance
$15 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

$15 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS7100, Silver, NS, OON, Dep29
HIOS Plan ID: 49526NY0450020-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,00
$2,000
$10 copayment
$20 copayment
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$3 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$35 copayment
50% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Aqua, Gold, NS, OON, Dep25
HIOS Plan ID: 49526NY0450031
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$50 copayment
$50 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: Aqua, Gold, NS, OON, Dep29
HIOS Plan ID: 49526NY0450032
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$50 copayment
$50 copayment
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance

$40 copayment

20% coinsurance

$40 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS110, Platinum, NS, OON, Dep25
HIOS Plan ID: 49526NY0450040
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$20 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$20 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$30 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
$250 Wellness Card

Plan Name: BlueCross BlueShield of Western NY

Product Name: POS110, Platinum, NS, OON, Dep29
HIOS Plan ID: 49526NY0450041
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$20 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
50% coinsurance
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$20 copayment

$35 copayment

$0 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

$30 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment
$250 Wellness Card

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Independent Health

Product Name: Standard Bronze ST OON Dep25
HIOS Plan ID: 18029NY1310009
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep25
HIOS Plan ID: 18029NY1260001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Gold ST OON Dep25
HIOS Plan ID: 18029NY1220001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Platinum ST OON Dep25
HIOS Plan ID: 18029NY1180001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Bronze ST OON Dep29
HIOS Plan ID: 18029NY1310010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Silver ST OON Dep29
HIOS Plan ID: 18029NY1260002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Gold ST OON Dep29
HIOS Plan ID: 18029NY1220002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Standard Platinum ST OON Dep29
HIOS Plan ID: 18029NY1180002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Independent Health

Product Name: Max Bronze NS INN Dep25 Adult Vision Nurse Helpline Telemedicine Wellness
HIOS Plan ID: 18029NY1360069
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$40 copayment
25% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
50% coinsurance
50% coinsurance
25% coinsurance
25% coinsurance
$75 copayment
50% coinsurance
25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

25% coinsurance
$40 copayment
25% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: Max Bronze NS INN Dep29 Adult Vision Nurse Helpline Telemedicine Wellness
HIOS Plan ID: 18029NY1360070
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$40 copayment
25% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
50% coinsurance
50% coinsurance
25% coinsurance
25% coinsurance
$75 copayment
50% coinsurance
25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance

25% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

25% coinsurance
$40 copayment
25% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$4 copayment
$30 copayment
50% copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep25 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260037-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
10% coinsurance
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
50% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$4 copayment
$30 copayment
50% copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Silver Coinsurance NS OON Dep29 Adult Vision Nurse Helpline
Telemedicine Wellness
HIOS Plan ID: 18029NY1260038-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
10% coinsurance
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
50% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Gold NS OON Dep25 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220021
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$45 copayment

$35 copayment

$25 copayment

$35 copayment

$45 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$45 copayment
$15 copayment
$45 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: iDirect Gold NS OON Dep29 Adult Vision Telemedicine Wellness
HIOS Plan ID: 18029NY1220022
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$1000 copayment
$150 copayment
$75 copayment
50% coinsurance
$45 copayment

$35 copayment

$25 copayment

$35 copayment

$45 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$45 copayment
$15 copayment
$45 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Telemedicine, Wellness Benefit Options

Plan Name: Independent Health

Product Name: FlexFit Platinum NS OON Dep25 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180021
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$10 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: Independent Health

Product Name: FlexFit Platinum NS OON Dep29 Adult Vision Nurse Helpline Telemedicine
Wellness
HIOS Plan ID: 18029NY1180022
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$5,000
$10,000
$10 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
50% coinsurance
$500 copayment
$150 copayment
$75 copayment
50% coinsurance
$30 copayment

$35 copayment

$10 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
$10 copayment
$30 copayment
Not covered
$20 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Vision, Nurse Helpline, Telemedicine, Wellness Benefit
Options

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0950004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0940010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0940004
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0930004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0950002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0940008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0940002
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0930002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Univera Healthcare

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0950012
Metal Level: Bronze
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness
Gym Membership

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
$ copayment

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance

Not covered
50% coinsurance
$0 copayment

Additional Non-Standard Benefits: Gym Membership Reimbursement, Health Savings Account

Plan Name: Univera Healthcare

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0950014
Metal Level: Bronze
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

Not covered
50% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008
Metal Level: Silver
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$15 copayment
$15 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0950008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$ copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance

$10 copayment
$10 copayment
Gym Membership
Reimbursement

Not covered
5% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010
Metal Level: Silver
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$ copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$ copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance

$15 copayment
$15 copayment
Gym Membership
Reimbursement

Not covered
20% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0950010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$ copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance

$10 copayment
$10 copayment
Gym Membership
Reimbursement

Not covered
5% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Univera Healthcare

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0940014
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment

$0 copayment

$30 copayment
$30 copayment

$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera Healthcare

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0940016
Metal Level: Gold
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$0
$0

$4,000
$8,000
$25 copayment
$40 copayment
$ copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$25 copayment
$40 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$40 copayment
Gym Membership
Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0930008
Metal Level: Platinum
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$25 copayment
Gym Membership
Reimbursement

Plan Name: Univera Healthcare

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0930010
Metal Level: Platinum
In-Network Benefits:

Out-of-Network Benefits Available:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic and Routine Lab
Services
Diagnostic and Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Services
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$ copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment

$30 copayment
$30 copayment
Gym Membership
Reimbursement

Not covered
$25 copayment
Gym Membership
Reimbursement

Greene County
Individual Market Products

Plan

Standard

Non-Standard

BlueCross BlueShield of Western NY

Capital District Physicians Health Plan

(CDPHP)

Emblem Health

Empire Blue Cross Blue Shield

Fidelis

Health Republic

MVP Health Care

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep25
HIOS Plan ID: 36346NY0480001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep25
HIOS Plan ID: 36346NY0480014-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep25
HIOS Plan ID: 36346NY0480026
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep25
HIOS Plan ID: 36346NY0480035
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Bronze ST INN Dep29
HIOS Plan ID: 36346NY0480002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Silver ST INN Dep29
HIOS Plan ID: 36346NY0480015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Gold ST INN Dep29
HIOS Plan ID: 36346NY0480027
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: BlueShield of Northeastern NY

Product Name: Platinum ST INN Dep29
HIOS Plan ID: 36346NY0480036
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
$250 Wellness Card

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
$250 Wellness Card

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep25
HIOS Plan ID: 88582NY0170001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep25
HIOS Plan ID: 88582NY0150001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Platinum Platinum ST INN Dep25
HIOS Plan ID: 88582NY0140001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep29
HIOS Plan ID: 88582NY020001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep29
HIOS Plan ID: 88582NY0260001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0290001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160012
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160014
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160018
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160028
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160030
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160020
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160022
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160107
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160109
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160115
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160117
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330005
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment
Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$30 copayment
20% coinsurance
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep29 Acupuncture Home Health Care
Three PCP visits are covered in full Wellness
HIOS Plan ID: 56184NY0150008-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$200 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$200 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150010
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical) $100 (Drug)

$1,700 (Medical) $200 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep29 Acupuncture Home Health
Care Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150011
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep29 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep29 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150014-01
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep25 Acupuncture Home Health

Care Three PCP visits are covered in full Wellness

HIOS Plan ID: 56184NY0150015-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$675
$1,350

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep25 Acupuncture Home Health Care

Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150018
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical)
$1,700 (Medical)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

$100 (Drug)
$200 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep25 Acupuncture Home

Health Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150019
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep25 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150020
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep25 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership
Reimbursement

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership
Reimbursement

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership
Reimbursement

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Hamilton County
Individual Market Products

Plan

Standard

Non-Standard

Capital District Physicians Health Plan

(CDPHP)

Excellus

Fidelis

Health Republic

MVP

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership, Youth
Sports

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

50% coinsurance

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Gym Membership Reimbursement, Massage

Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
0% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9.000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
$25 copayment
$0 copayment
No covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
0% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9.000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
$25 copayment
$0 copayment
No covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$30 copayment
20% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Herkimer County
Individual Market Products

Plan

Standard

Non-Standard

Capital District Physicians Health Plan

(CDPHP)

Excellus

MVP

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep25
HIOS Plan ID: 94788NY0280059
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep25
HIOS Plan ID: 94788NY0280055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep25
HIOS Plan ID: 94788NY0280054
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep25
HIOS Plan ID: 94788NY0280053
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Non-Qualified 40 Bronze ST INN Dep29
HIOS Plan ID: 94788NY0280070
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 30 Silver ST INN Dep29
HIOS Plan ID: 94788NY0280066-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 20 Gold ST INN Dep29
HIOS Plan ID: 94788NY0280065
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts for
Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 10 Platinum ST INN Dep29
HIOS Plan ID: 94788NY0280064
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Reimbursement and Wellness discounts
for Youth Sports and Other Wellness Services

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280029
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 42 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280030
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,300
$6,600

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$4 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280033
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 41 Bronze NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280034
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,450
$12,900
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep25 Adult Vision Lasik
HIOS Plan ID: 94788NY0280017
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,000
$12,000
20% coinsurance
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
25% coinsurance
40% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280022
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
0% coinsurance
0% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$50 copayment

0% coinsurance

$50 copayment

0% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HDHMO Qualified 31 Silver NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280021
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$750
$1,500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,500
$3,000
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$50 copayment
$80 copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: Embrace Health HMO Coinsurance 32 Silver NS INN Dep29 Adult Vision Lasik
Wellness
HIOS Plan ID: 94788NY0280018
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
20% coinsurance
20% coinsurance
0% coinsurance

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

50% coinsurance
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

0% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280007
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 21 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280008
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$400
$800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,600
$13,200
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$250 copayment
$75 copayment
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Hybrid 22 Gold NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$500
$1,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$25 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
50% coinsurance
50% coinsurance
20% coinsurance
20% coinsurance
$35 copayment
50% coinsurance
$50 copayment

$40 copayment

$50 copayment

$40 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 12 Platinum NS INN Dep29 Adult Vision Lasik
HIOS Plan ID: 94788NY0280002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,600
$13,200
$10 copayment
$10 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$40 copayment
$70 copayment
$500 copayment
$100 copayment
$20 copayment
50% coinsurance
$10 copayment

$35 copayment

$10 copayment

$35 copayment

$10 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$0 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep25 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280049
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Capital District Physicians Health Plan, Inc. (CDPHP)

Product Name: HMO Copayment 11 Platinum NS INN Dep29 Adult Vision Lasik Wellness
HIOS Plan ID: 94788NY0280050
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$20 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$4 copayment
$30 copayment
$60 copayment
$750 copayment
$75 copayment
$30 copayment
50% coinsurance
$20 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

$20 copayment
$20 copayment
$20 copayment
Not covered
$20 copayment
Gym Reimbursement and
Wellness discounts for Youth
Sports and Other Wellness
Services

Additional Non-Standard Benefits: Acupuncture, Adult Vision, Lasik

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

50% coinsurance

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bassett Preferred Silver Silver NS INN Dep29
HIOS Plan ID: 78124NY0920006
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,250
$2,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1250 copayment
$250 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$50 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bassett Preferred Silver Silver NS INN Dep29
HIOS Plan ID: 78124NY0920006-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,250
$2,500

$5,200
$10,400
$30 copayment
$50 copayment

$4,250
$8,500
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,250 copayment
$250 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$50 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bassett Preferred Silver Silver NS INN Dep29
HIOS Plan ID: 78124NY0920006-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$250 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

0% coinsurance
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bassett Preferred Silver Silver NS INN Dep29
HIOS Plan ID: 78124NY0920006-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,000
$4,000
$5 copayment
$10 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$25 copayment
$50 copayment
$50 copayment
$100 copayment
$25 copayment
$10 copayment
50% coinsurance
$10 copayment

$35 copayment

$5 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

0% coinsurance
$5 copayment
$10 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bassett Preferred Silver Silver NS INN Dep25
HIOS Plan ID: 78124NY0920008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,250
$2,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,250 copayment
$250 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$50 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bassett Preferred Silver Silver NS INN Dep25
HIOS Plan ID: 78124NY0920008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,250
$2,500

$5,200
$10,400
$30 copayment
$50 copayment

$4,250
$8,500
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,250 copayment
$250 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$50 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bassett Preferred Silver Silver NS INN Dep25
HIOS Plan ID: 78124NY0920008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$250 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

0% coinsurance
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bassett Preferred Silver Silver NS INN Dep25
HIOS Plan ID: 78124NY0920008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,000
$4,000
$5 copayment
$10 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$25 copayment
$50 copayment
$100 copayment
$25 copayment
$10 copayment
50% coinsurance
$10 copayment

$35 copayment

$5 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

0% coinsurance
$5 copayment
$10 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bassett Preferred Gold Gold NS INN Dep29
HIOS Plan ID: 78124NY0920002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$4,000
$8,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Bassett Preferred Gold Gold NS INN Dep25
HIOS Plan ID: 78124NY0920004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$4,000
$8,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$500 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Jefferson County
Individual Market Products

Plan

Standard

Non-Standard

Excellus

Fidelis

MVP

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

50% coinsurance

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Kings County
Individual Market Products

Plan

Standard

Non-Standard

Affinity

Emblem Health

Empire Blue Cross Blue Shield

Fidelis

Healthfirst

Health Republic

Metroplus

North Shore - LIJ Care Connect

Oscar

United Healthcare

Wellcare

Plan Name: Affinity Health Plan

Product Name: Affinity Access Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010003
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 57165NY0010001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010013
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010011
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 57165NY0010010
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Bronze ST INN Dep25
HIOS Plan ID: 57165NY0020004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep25
HIOS Plan ID: 57165NY0020003
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep25
HIOS Plan ID: 57165NY0020003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep25
HIOS Plan ID: 57165NY0020003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep25
HIOS Plan ID: 57165NY0020003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Gold ST INN Dep25
HIOS Plan ID: 57165NY0020002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Platinum ST INN Dep25
HIOS Plan ID: 57165NY0020001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Bronze ST INN Dep29
HIOS Plan ID: 57165NY0020013
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep29
HIOS Plan ID: 57165NY0020012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep29
HIOS Plan ID: 57165NY0020012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep29
HIOS Plan ID: 57165NY0020012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Silver ST INN Dep29
HIOS Plan ID: 57165NY0020012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Gold ST INN Dep29
HIOS Plan ID: 57165NY0020011
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Affinity Health Plan

Product Name: Affinity Access Platinum ST INN Dep29
HIOS Plan ID: 57165NY0020010
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep25
HIOS Plan ID: 88582NY0170001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep25
HIOS Plan ID: 88582NY0160001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep25
HIOS Plan ID: 88582NY0150001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Platinum Platinum ST INN Dep25
HIOS Plan ID: 88582NY0140001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Bronze Bronze ST INN Dep29
HIOS Plan ID: 88582NY020001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0230001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Gold Gold ST INN Dep29
HIOS Plan ID: 88582NY0260001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Emblem Health

Product Name: Select Care Silver Silver ST INN Dep29
HIOS Plan ID: 88582NY0290001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160012
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160014
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 3000 for HSA Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160018
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2000 Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160024-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 600 Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160028
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 0 Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160030
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160006
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 6000 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160020
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,000
$12,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$45 copayment
20% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
$600 copayment
$500 copayment
$50 copayment
20% coinsurance
20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance

20% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
$0

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 5600 Bronze NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160022
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,600
$11,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$15 copayment
40% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
$1000 copayment
$500 copayment
$50 copayment
40% coinsurance
40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance

40% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

40% coinsurance
40% coinsurance
40% coinsurance
25% coinsurance
0% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,250
$4,500

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,800
$11,600
$30 copayment
25% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
25% coinsurance
25% coinsurance

$50 copayment

25% coinsurance

$50 copayment

25% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
$0

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,750
$3,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
20% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$4,000
$8,000
$15 copayment
15% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

15% coinsurance
15% coinsurance
15% coinsurance
$250 copayment
$100 copayment
$30 copayment
15% coinsurance
15% coinsurance

$35 copayment

15% coinsurance

$35 copayment

15% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

15% coinsurance
15% coinsurance
15% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2250 Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160026-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,600
$3,200
$5 copayment
10% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$100 copayment
$50 copayment
$25 copayment
10% coinsurance
10% coinsurance

$35 copayment

10% coinsurance

$35 copayment

10% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160099-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
0% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,100
$2,200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,100
$2,200
$0 copayment
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 2450 for HSA Silver NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160101-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
0% coinsurance
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160107
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 1000 Gold NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160109
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 25
HIOS Plan ID: 80519NY0160115
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield

Product Name: Empire HMO 200 Platinum NS INN Pediatric Dental Dep 29
HIOS Plan ID: 80519NY0160117
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$200
$400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,500
$7,000
$20 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$50 copayment
$300 copayment
$150 copayment
$50 copayment
5% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

5% coinsurance
5% coinsurance
5% coinsurance
$0 copayment
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness:
Gym Membership
Gym Membership
Reimbursement
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
25, a Multi-State Plan
HIOS Plan ID: 80519NY0330003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 25, a
Multi-State Plan
HIOS Plan ID: 80519NY0330005
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,450
$4,900

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,450
$12,900
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,250
$4,500

$5,200
$10,400
$30 copayment
$50 copayment

$3,750
$7,500
10% coinsurance
10% coinsurance
0$ copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% copayment
10% coinsurance

$50 copayment

10% coinsurance

$50 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits,
150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies
$25 copayment
(PT/OT/ST)
Diagnostic & Routine Lab
$35 copayment
Services
Diagnostic & Routine
$35 copayment
Imaging
Outpatient Surgery Services $75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health $15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness:
Gym Membership
Gym Membership
Reimbursement
Reimbursement

How Does this Non-Standard

Product Compare?
$1,100
$2,200
$1,100
$2,200
0% coinsurance
0% coinsurance
0% copayment
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance
Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 2450, Silver, NS, INN, Pediatric Dental, Dep
29, a Multi-State Plan
HIOS Plan ID: 80519NY0330011-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$475
$950

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$475
$950
0% coinsurance
0% coinsurance
0% copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance
0% coinsurance

$35 copayment

0% coinsurance

$35 copayment

0% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

0% coinsurance
0% coinsurance
0% coinsurance
25% coinsurance
0% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Health Savings Account Eligible

Plan Name: Empire Blue Cross Blue Shield Multi-State Plan

Product Name: Empire Blue Cross Blue Shield HMO 1000 Gold NS INN Pediatric Dental Dep 29, a
Multi-State Plan
HIOS Plan ID: 80519NY0330013
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000
$2,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6.550
$13,100
$30 copayment
10% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$40 copayment
10% coinsurance
$1,000 copayment
$200 copayment
$50 copayment
10% coinsurance
10% coinsurance

$40 copayment

10% coinsurance

$40 copayment

10% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

10% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep25
HIOS Plan ID: 71644NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep25
HIOS Plan ID: 71644NY0010002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep25
HIOS Plan ID: 71644NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep25
HIOS Plan ID: 71644NY0010004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Bronze ST INN Dep29
HIOS Plan ID: 71644NY0090001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Silver ST INN Dep29
HIOS Plan ID: 71644NY0090002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Gold ST INN Dep29
HIOS Plan ID: 71644NY0090003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: EssentialCare Platinum ST INN Dep29
HIOS Plan ID: 71644NY0090004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupunctur

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
0% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9.000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
$25 copayment
$0 copayment
No covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0040002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
0% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9.000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
$25 copayment
$0 copayment
No covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: PrimarySelect PCMH Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0150002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$30 copayment
20% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0700001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$3,800
$7,600

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,300
$8,600
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,000
$6,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,600
$7,200
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$75 copayment
0% coinsurance
$0 copayment

$50 copayment

$20 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$700
$1,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,300
$2,600
0% coinsurance
0% coinsurance
0% coinsurance

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
0% coinsurance

$35 copayment

$20 copayment

$35 copayment

0% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

0% coinsurance
0% coinsurance
0% coinsurance
Not covered
0% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0720001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$20 copayment
0% coinsurance
0% coinsurance
$0 copayment
$250 copayment
$75 copayment
$0 copayment
$0 copayment

$35 copayment

$20 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Gold NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$250
$500

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,500
$7,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$40 copayment

$75 copayment

$40 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$25 copayment
20% coinsurance
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0730001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Gold NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0750001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,950
$3,900

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2,500
$5,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$20 copayment
$0 copayment
$0 copayment
$0 copayment
$250 copayment
$50 copayment
$0 copayment
$0 copayment

$40 copayment

$20 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: PrimarySelect Platinum NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$15 copayment
$0 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Platinum NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130004
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,400
$2,800
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$60 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$15 copayment
0% coinsurance
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Healthfirst

Product Name: Healthfirst Bronze Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020003
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020007
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020007-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020007-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020007-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Gold Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020011
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Platinum Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020015
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Bronze Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Silver Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Gold Leaf ST INN Dep29
HIOS Plan ID: 91237NY0020012
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Healthfirst

Product Name: Healthfirst Platinum Leaf ST INN Dep25
HIOS Plan ID: 91237NY0020016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Bronze Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020052
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,000
$6,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
20% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Bronze Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020053
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,000
$6,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
20% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020054
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,500
$11,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020054-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020054-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020054-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020055
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,500
$11,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020055-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020055-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Silver Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020055-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Gold Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020056
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$40 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$25 copayment
$25 copayment
$25 copayment
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Gold Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020057
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$40 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$25 copayment
$25 copayment
$25 copayment
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Platinum Leaf Premier NS INN Dep25
HIOS Plan ID: 91237NY0020058
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: HealthFirst PHSP

Product Name: Healthfirst Platinum Leaf Premier NS INN Dep29
HIOS Plan ID: 91237NY0020059
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental Care, Adult Vision Care

Plan Name: MetroPlus Health Plan

Product Name: BronzePlus-B1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0040001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0040001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0040001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0040001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: GoldPlus-G1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0080001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus

Product Name: PlatinumPlus-P1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0110001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: BronzePlus-B1, ST, INN, Dep29, Pediatric Dental
HIOS Plan ID: 11177NY0010002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep29, Pediatric Dental
HIOS Plan ID: 11177NY0040002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep29, Pediatric Dental
HIOS Plan ID: 11177NY0040002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep29, Pediatric Dental
HIOS Plan ID: 11177NY0040002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: SilverPlus-S1, ST, INN, Dep29, Pediatric Dental
HIOS Plan ID: 11177NY0040002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus Health Plan

Product Name: GoldPlus-G1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0080002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus

Product Name: PlatinumPlus-P1, ST, INN, Dep25, Pediatric Dental
HIOS Plan ID: 11177NY0110002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MetroPlus

Product Name: BronzePlus-B2, NS, INN, Dep25, Pediatric and Adult Dental
HIOS Plan ID: 11177NY0160001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,000
$6,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental

Plan Name: MetroPlus

Product Name: BronzePlus-B2, NS, INN, Dep29, Pediatric and Adult Dental
HIOS Plan ID: 11177NY0160002
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,000
$6,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070001
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: SilverPlus-S2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0070002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: GoldPlus-G2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$40 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$25 copayment
$25 copayment
$25 copayment
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: GoldPlus-G2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0170002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
Inpatient Services
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$40 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$25 copayment
$25 copayment
$25 copayment
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: PlatinumPlus-P2, NS, INN, Dep25, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0180001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance

$30 copayment

$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: MetroPlus

Product Name: PlatinumPlus-P2, NS, INN, Dep29, Pediatric and Adult Dental, Adult and Pediatric
Vision
HIOS Plan ID: 11177NY0180002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance
$25 copayment

$35 copayment

$35 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Adult Dental, Adult Vision

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Bronze ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0190001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0210001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0210001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0210001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0210001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0230001
Metal Level: Gold

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Gold Benefits

$600
$1,200
$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment
$40 copayment
$40 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum ST INN Pediatric Dental Dep 25
HIOS Plan ID: 82483NY0250001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Bronze ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0200001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Bronze Benefits

$3,000
$6,000
$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance
$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0220001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0220001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 200-250% FPL

$1,200
$2,400
$5,200
$10,400
$30 copayment
$50 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0220001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 150-200% FPL

$250
$500
$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment
$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment
$35 copayment
$35 copayment
$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0220001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits, 100-150% FPL

$0
$0
$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment
$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment
$35 copayment
$35 copayment
$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0240001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum ST INN Pediatric Dental Dep 29
HIOS Plan ID: 82483NY0260001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1270001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical) $100 (Drug)

$0 (Medical) $300 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$30 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
$500 copayment
$200 copayment
$30 copayment
$200 copayment
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1280001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical) $100 (Drug)

$0 (Medical) $300 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$30 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
$500 copayment
$200 copayment
$30 copayment
$200 copayment
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1290001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$30 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
$500 copayment
$200 copayment
$30 copayment
$200 copayment
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Platinum NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1300001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$30 copayment
$30 copayment
0% coinsurance

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
$500 copayment
$200 copayment
$30 copayment
$200 copayment
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1310001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000 (Medical) $100 (Drug)

$2,000 (Medical) $300 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,000
$6,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
$30 copayment

$40 copayment

$50 copayment

$40 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1320001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000 (Medical) $100 (Drug)

$2,000 (Medical) $300 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,000
$6,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
$30 copayment

$40 copayment

$50 copayment

$40 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1330001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000 (Medical) $0 (Drug)

$2,000 (Medical) $0 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,000
$6,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
$30 copayment

$40 copayment

$50 copayment

$40 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Gold NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1340001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,000 (Medical) $0 (Drug)

$2,000 (Medical) $0 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$3,000
$6,000
$30 copayment
$50 copayment
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
10% coinsurance
$200 copayment
$50 copayment
10% coinsurance
$30 copayment

$40 copayment

$50 copayment

$40 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1350001-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$4,000 (Medical) $100 (Drug)

$8,000 (Medical) $300 (Drug)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,600
$13,200
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$40 copayment
$40 copayment
$40 copayment
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1350001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,400 (Medical) $100 (Drug)

$6,800 (Medical) $300 (Drug)

$5,200
$10,400
$30 copayment
$50 copayment

$5,200
$10,400
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$40 copayment
$40 copayment
$40 copayment
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1350001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$500 (Medical) $0 (Drug)

$1,000 (Medical) $0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
20% coinsurance
$100 copayment
$35 copayment
20% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture High Rx
HIOS Plan ID: 82483NY1350001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
20% coinsurance
$75 copayment
$20 copayment
20% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1360001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$4,000 (Medical) $100 (Drug)

$8,000 (Medical) $300 (Drug)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,600
$13,200
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$40 copayment
$40 copayment
$40 copayment
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1360001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,400 (Medical) $100 (Drug)

$6,800 (Medical) $300 (Drug)

$5,200
$10,400
$30 copayment
$50 copayment

$5,200
$10,400
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$35 copayment
$75 copayment
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$40 copayment
$40 copayment
$40 copayment
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1360001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$500 (Medical) $0 (Drug)

$1,000 (Medical) $0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
20% coinsurance
$100 copayment
$35 copayment
20% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture High Rx
HIOS Plan ID: 82483NY1360001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
20% coinsurance
$75 copayment
$20 copayment
20% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1370001-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$4,000 (Medical) $0 (Drug)

$8,000 (Medical) $0 (Drug)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,600
$13,200
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$40 copayment
$40 copayment
$40 copayment
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1370001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,400 (Medical) $0 (Drug)

$6,800 (Medical) $0 (Drug)

$5,200
$10,400
$30 copayment
$50 copayment

$5,200
$10,400
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$40 copayment
$40 copayment
$40 copayment
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1370001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$500 (Medical) $0 (Drug)

$1,000 (Medical) $0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
20% coinsurance
$100 copayment
$35 copayment
20% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 25 Acupuncture Low Rx
HIOS Plan ID: 82483NY1370001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
20% coinsurance
$75 copayment
$20 copayment
20% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1380001-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$4,000 (Medical) $0 (Drug)

$8,000 (Medical) $0 (Drug)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,600
$13,200
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$40 copayment
$40 copayment
$40 copayment
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1380001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,400 (Medical) $0 (Drug)

$6,800 (Medical) $0 (Drug)

$5,200
$10,400
$30 copayment
$50 copayment

$5,200
$10,400
$40 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$50 copayment
50% coinsurance
20% coinsurance
$350 copayment
$60 copayment
20% coinsurance
$40 copayment

$50 copayment

$60 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$40 copayment
$40 copayment
$40 copayment
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1380001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$500 (Medical) $0 (Drug)

$1,000 (Medical) $0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$9 copayment
$20 copayment
$40 copayment
20% coinsurance
$100 copayment
$35 copayment
20% coinsurance
$15 copayment

$35 copayment

$35 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Silver NS INN Pediatric Dental Dep 29 Acupuncture Low Rx
HIOS Plan ID: 82483NY1380001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$30 copayment
20% coinsurance
$75 copayment
$20 copayment
20% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$10 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Bronze NS INN Pediatric Dental Dep 25 Acupuncture
HIOS Plan ID: 82483NY1910001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,400
$6,800

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
30% coinsurance
30% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$15 copayment
$35 copayment
$75 copayment
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: North Shore-LIJ CareConnect Insurance Company

Product Name: CareConnect EPO Bronze NS INN Pediatric Dental Dep 29 Acupuncture
HIOS Plan ID: 82483NY1920001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,400
$6,800

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
30% coinsurance
30% coinsurance
0% coinsurance

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$15 copayment
$35 copayment
$75 copayment
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance

30% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Oscar Insurance

Product Name: Oscar Bronze ST INN Dep25
HIOS Plan ID: 74289NY0080001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep25
HIOS Plan ID: 74289NY0050001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep25
HIOS Plan ID: 74289NY0050001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep25
HIOS Plan ID: 74289NY0050001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep25
HIOS Plan ID: 74289NY0050001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Gold ST INN Dep25
HIOS Plan ID: 74289NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Platinum ST INN Dep25
HIOS Plan ID: 74289NY0010001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Bronze ST INN Dep29
HIOS Plan ID: 74289NY0080002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep29
HIOS Plan ID: 74289NY0050002
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep29
HIOS Plan ID: 74289NY0050002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep29
HIOS Plan ID: 74289NY0050002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Silver ST INN Dep29
HIOS Plan ID: 74289NY0050002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Gold ST INN Dep29
HIOS Plan ID: 74289NY0030002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance

Product Name: Oscar Platinum ST INN Dep29
HIOS Plan ID: 74289NY0010002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Platinum NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0020001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$150 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Platinum NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0020002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,000
$4,000
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$30 copayment
$150 copayment
$500 copayment
$100 copayment
$55 copayment
10% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Gold NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0040001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment (after free visit
limit is reached)
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Gold NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0040002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment (after free visit
limit is reached)
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$25 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,000
$10,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,100
$12,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,700
$5,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$350
$700

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,300
$4,600
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$20 copayment
$150 copayment
$250 copayment
$125 copayment
$50 copayment
10% copayment
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$75 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep25 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,500
$3,000
$10 copayment (after free visit
limit is reached)
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$15 copayment
$130 copayment
$100 copayment
$100 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$10 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$25 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,000
$10,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,100
$12,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,700
$5,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$350
$700

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,300
$4,600
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$20 copayment
$150 copayment
$250 copayment
$125 copayment
$50 copayment
10% copayment
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$75 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Silver NS INN Dep29 Free Generic Drugs Free PCP Visits Wellness
HIOS Plan ID: 74289NY0060002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,500
$3,000
$10 copayment (after free visit
limit is reached)
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$15 copayment
$130 copayment
$100 copayment
$100 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$10 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$25 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,600
$11,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$2,000 copayment
$250 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,950
$9,900
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$2,000 copayment
$250 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$275
$550

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,550
$5,100
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$20 copayment
$150 copayment
$250 copayment
$125 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$75 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,200
$2,400
$10 copayment (after free visit
limit is reached)
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$15 copayment
$130 copayment
$100 copayment
$100 copayment
$30 copayment
5% coinsurance
$15 copayment

$35 copayment

$10 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$25 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,600
$11,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$2,000 copayment
$250 copayment
$70 copayment
30% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,950
$9,900
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$0 copayment
$35 copayment
$150 copayment
$2000 copayment
$250 copayment
$70 copayment
25% coinsurance
$30 copayment

$50 copayment

$30 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$275
$550

$2,000
$4,000
$15 copayment

$2,550
$5,100
$15 copayment (after free visit
limit is reached)
$35 copayment
$0 copayment

Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services

$35 copayment
$0 copayment

Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$20 copayment
$150 copayment
$250 copayment
$325 copayment (maternity)
$125 copayment
$50 copayment
10% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$35 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$75 copayment
$15 copayment
$15 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

$9 copayment
$20 copayment
$40 copayment
$250 copayment

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Silver NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0070002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment

$1,200
$2,400
$10 copayment (after free visit
limit is reached)
$20 copayment
$0 copayment

Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services

$20 copayment
$0 copayment

Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$15 copayment
$130 copayment
$100 copayment
$125 copayment (maternity)
$100 copayment
$30 copayment
5% copayment
$15 copayment

$35 copayment

$10 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$25 copayment
$10 copayment
$10 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

$6 copayment
$15 copayment
$30 copayment
$100 copayment

Additional Non-Standard Benefits: Free Generic Drugs

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Bronze NS INN Dep25 Free PCP Visits Wellness
HIOS Plan ID: 74289NY0090001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance

$6,600
$13,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services

50% coinsurance
0% coinsurance

Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$35 copayment
$150 copayment
$1500 copayment
$1600 copayment (maternity)
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

50% coinsurance

$30 copayment

50% coinsurance

$50 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

$10 copayment
$35 copayment
$70 copayment
50% coinsurance

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Plus Bronze NS INN Dep29 Free PCP Visits Wellness
HIOS Plan ID: 74289NY0090002
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance

$6,600
$13,200
$30 copayment (after free visit
limit is reached)
$50 copayment
$0 copayment

Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services

50% coinsurance
0% coinsurance

Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$35 copayment
$150 copayment
$1500 copayment
$1600 copayment (maternity)
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

50% coinsurance

$30 copayment

50% coinsurance

$50 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$100 copayment
$30 copayment
$30 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

$10 copayment
$35 copayment
$70 copayment
50% coinsurance

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Bronze NS INN Dep25 Free PCP Visits Wellness
HIOS Plan ID: 74289NY0100001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

50% coinsurance

$0 copayment

50% coinsurance

$0 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Edge Bronze NS INN Dep29 Free PCP Visits Wellness
HIOS Plan ID: 74289NY0100002
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

50% coinsurance

$0 copayment

50% coinsurance

$0 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 1000 Platinum NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0410001
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$1,000
$2,000

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 1000 Platinum NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0410002
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$1,000
$2,000

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,000
$2,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 4500 Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0500001
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$4,500
$9,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 4500 Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0500001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$3,500
$7,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$3,500
$7,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 4500 Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0500001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$1,200
$2,400

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,200
$2,400
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 4500 Silver NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0500001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$500
$1,000

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,200
$2,400
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$35 copayment

$0 copayment

$35 copayment

$0 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 6600 Bronze NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0520001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

50% coinsurance

$0 copayment

50% coinsurance

$0 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 6600 Bronze NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0520002
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$6,600
$13,200

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,600
$13,200
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

50% coinsurance

$0 copayment

50% coinsurance

$0 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 2000 Gold NS INN Dep25 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0540001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$2000
$4,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$40 copayment

$0 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Oscar Insurance Co.

Product Name: Oscar Simple 2000 Gold NS INN Dep29 Free Generic Drugs Free PCP Visits
Wellness
HIOS Plan ID: 74289NY0540002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$2000
$4,000

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$2000
$4,000
$0 copayment (after free visit limit
is reached)
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment

$40 copayment

$0 copayment

$40 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010013
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010003
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 54235NY0010001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010014
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010006-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: United Healthcare

Product Name: United Healthcare Compass Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 54235NY0010002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010003-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 39595NY0010005
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010007
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Wellcare of New York

Product Name: WellCare Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 39595NY0010010
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
30% coinsurance
30% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

$50 copayment

30% coinsurance

$50 copayment

30% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400

$4,000
$8,000

$30 copayment
$50 copayment
$0 copayment

$30 copayment
$40 copayment
$0

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$55 copayment
30% coinsurance
30% coinsurance
$40 copayment
25% coinsurance
$30 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

30% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$175
$350

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$15 copayment
$30 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$25 copayment
$45 copayment
$250 copayment
$75 copayment
$30 copayment
10% coinsurance
$20 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$0 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep25 Acupuncture
HIOS Plan ID: 39595NY0010015-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$975
$1950
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$6 copayment
$15 copayment
$35 copayment
$100 copayment
$75 copayment
$20 copayment
5% coinsurance
$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,500
$5,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
30% coinsurance
30% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

$50 copayment

30% coinsurance

$50 copayment

30% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,500
$5,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,000
$8,000
$30 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$55 copayment
30% coinsurance
30% coinsurance
$40 copayment
25% coinsurance
$30 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

30% coinsurance
$30 copayment
$30 copayment
$30 copayment
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$175
$350

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$15 copayment
$30 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$25 copayment
$45 copayment
$250 copayment
$75 copayment
$30 copayment
10% coinsurance
$20 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$0 copayment
$35 copayment
$15 copayment
$15 copayment
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Plan Name: WellCare

Product Name: WellCare Silver NS INN Family Dental OTC Dep29 Acupuncture
HIOS Plan ID: 39595NY0010016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$975
$1,950
$10 copayment
$20 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance

$6 copayment
$15 copayment
$35 copayment
$100 copayment
$75 copayment
$20 copayment
5% coinsurance

$15 copayment

$10 copayment

$35 copayment

$20 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$0 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Family Dental

Lewis County
Individual Market Products

Plan

Standard

Non-Standard

Excellus

Fidelis

MVP

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

50% coinsurance

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep25
HIOS Plan ID: 56184NY0140010
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep25
HIOS Plan ID: 56184NY0140012-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep25
HIOS Plan ID: 56184NY0140014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep25
HIOS Plan ID: 56184NY0140016
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier HDHP Bronze Bronze ST INN Dep29
HIOS Plan ID: 56184NY0140011
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Silver Silver ST INN Dep29
HIOS Plan ID: 56184NY0140013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Gold Gold ST INN Dep29
HIOS Plan ID: 56184NY0140015
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP Health Care

Product Name: MVP Premier Platinum Platinum ST INN Dep29
HIOS Plan ID: 56184NY0140017
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep29 Acupuncture Home Health Care
Three PCP visits are covered in full Wellness
HIOS Plan ID: 56184NY0150008-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$200 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,200
$2,400

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$225 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$200 copayment
$50 copayment
$200 copayment
Not covered
$60 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150009-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep29 Acupuncture Home Health Care
Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150010
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical) $100 (Drug)

$1,700 (Medical) $200 (Drug)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep29 Acupuncture Home Health
Care Three PCP visits covered in full Wellness
HIOS Plan ID: 56184NY0150011
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep29 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$50 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep29 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150013-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep29 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150014-01
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 2 Bronze NS INN Dep25 Acupuncture Home Health

Care Three PCP visits are covered in full Wellness

HIOS Plan ID: 56184NY0150015-01
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$8 copayment
$40 copayment
$60 copayment
$300 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

50% coinsurance

$60 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$300 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,900 (Medical)
$3,800 (Medical)

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000 (Medical)
$2,000 (Medical)

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$200 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$200 (Medical)
$400 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$25 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 1 Silver NS INN Dep25 Acupuncture Home Health

Care PCP visits no Deductible Wellness

HIOS Plan ID: 56184NY0150016-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25 (Medical)
$50 (Medical)

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$600
$1,200
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$50 (Drug)
$100 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-01
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$30 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$675
$1,350

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$35 copayment
$60 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$8 copayment
$35 copayment
$70 copayment
$200 copayment
$350 copayment
$60 copayment
50% coinsurance
$60 copayment

$50 copayment

$60 copayment

$50 copayment

$125 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$200 copayment
$50 copayment
$35 copayment
Not covered
$60 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$100
$200

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$25 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$25 copayment
$50 copayment
$50 copayment
$200 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$25 copayment

$35 copayment

$50 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$50 copayment
$25 copayment
$5 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Silver 2 Silver NS INN Dep25 Acupuncture Home Health

Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150017-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$25
$50

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$5 copayment
$15 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$150 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$20 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$40 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Gold 1 Gold NS INN Dep25 Acupuncture Home Health Care

Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150018
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$850 (Medical)
$1,700 (Medical)

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$45 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$100 copayment
$300 copayment
$45 copayment
50% coinsurance
$45 copayment

$40 copayment

$45 copayment

$40 copayment

$60 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$45 copayment
$15 copayment
Not covered
$45 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

$100 (Drug)
$200 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 1 Platinum NS INN Dep25 Acupuncture Home

Health Care Three PCP visits covered in full Wellness

HIOS Plan ID: 56184NY0150019
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$0 (Drug)
$0 (Drug)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$3,000
$6,000
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$100 copayment
$100 copayment
$40 copayment
50% coinsurance
$40 copayment

$35 copayment

$40 copayment

$35 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Three PCP Visits Paid in Full

Plan Name: MVP

Product Name: MVP Premier Plus Platinum 2 Platinum NS INN Dep25 Acupuncture Home

Health Care Wellness

HIOS Plan ID: 56184NY0150020
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0 (Medical)
$0 (Medical)

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,500
$5,000
$5 copayment
$30 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
50% coinsurance
$30 copayment

$35 copayment

$30 copayment

$35 copayment

$30 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$50 copayment
$30 copayment
$5 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$0 (Drug)
$0 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus Bronze 1 Bronze NS INN Dep25 Acupuncture Home Health

Care Wellness
HIOS Plan ID: 56184NY0150021
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$3,500 (Medical)
$7,000 (Medical)

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$35 copayment
$80 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$40 copayment
50% coinsurance
$300 copayment
50% coinsurance
$80 copayment
50% coinsurance
$80 copayment

50% coinsurance

$80 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$300 copayment
$50 copayment
$35 copayment
Not covered
$80 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

$200 (Drug)
$400 (Drug)

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200004
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200005-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep29 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200006
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Bronze 3 Bronze NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200007
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,000
$8,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$30 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$5 copayment
$40 copayment
$60 coinsurance
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

50% coinsurance

$50 copayment

50% coinsurance

$100 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$100 copayment
$50 copayment
$30 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$1,500
$3,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$25 copayment
$50 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$40 copayment
$60 copayment
$100 copayment
$300 copayment
$50 copayment
50% coinsurance
$50 copayment

$50 copayment

$50 copayment

$50 copayment

$50 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$100 copayment
$50 copayment
$25 copayment
Not covered
$50 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$1,000
$2,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$5,200
$10,400
$5 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$15 copayment
$40 copayment
$60 copayment
$50 copayment
$200 copayment
$40 copayment
50% coinsurance
$40 copayment

$50 copayment

$40 copayment

$50 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$50 copayment
$40 copayment
$5 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$15 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$40 copayment
$60 copayment
$50 copayment
$100 copayment
$15 copayment
50% coinsurance
$15 copayment

$35 copayment

$15 copayment

$35 copayment

$15 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

$50 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Silver 3 Silver NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$50
$100

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$2,250
$4,500
$5 copayment
$5 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$15 copayment
$35 copayment
$40 copayment
$50 copayment
$5 copayment
50% coinsurance
$5 copayment

$35 copayment

$5 copayment

$35 copayment

$5 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

$40 copayment
$5 copayment
$5 copayment
Not covered
$5 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: MVP

Product Name: MVP Premier Plus HDHP Gold 2 Gold NS INN Dep25 Acupuncture Home

Health Care Wellness Drugs Wellness

HIOS Plan ID: 56184NY0200009
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$1,400
$2,800

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$6,350
$12,700
$5 copayment
$15 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$15 copayment
$25 copayment
$25 copayment
$75 copayment
$15 copayment
50% coinsurance
$15 copayment

$40 copayment

$15 copayment

$40 copayment

$15 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$25 copayment
$15 copayment
$5 copayment
Not covered
$15 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Livingston County
Individual Market Products

Plan

Standard

Non-Standard

Excellus

Fidelis

Health Republic

MVP

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep25
HIOS Plan ID: 78124NY0900004
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep25
HIOS Plan ID: 78124NY0890010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep25
HIOS Plan ID: 78124NY0890004
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep25
HIOS Plan ID: 78124NY0880004
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Bronze Standard Bronze ST INN Dep29
HIOS Plan ID: 78124NY0900002
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Silver Standard Silver ST INN Dep29
HIOS Plan ID: 78124NY0890008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Gold Standard Gold ST INN Dep29
HIOS Plan ID: 78124NY0890002
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus Blue Cross Blue Shield

Product Name: Platinum Standard Platinum ST INN Dep29
HIOS Plan ID: 78124NY0880002
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep29
HIOS Plan ID: 78124NY0900012
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

50% coinsurance

Plan Name: Excellus

Product Name: Bronze Select Bronze NS INN Dep25
HIOS Plan ID: 78124NY0900014
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$4,500
$9,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
50% coinsurance
50% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
40% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

50% coinsurance
50% coinsurance
50% coinsurance
Not covered
50% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment

$5 copayment
$45 copayment
$90 copayment

$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep29
HIOS Plan ID: 78124NY0900008-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$5,000
$10,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment

$3,000
$6,000
20% coinsurance
20% coinsurance
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$50 copayment

20% coinsurance

$50 copayment

20% coinsurance

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$250
$500

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,650
$3,300
20% coinsurance
20% coinsurance
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$5 copayment
$45 copayment
$90 copayment
20% coinsurance
20% coinsurance
20% coinsurance
50% coinsurance
20% coinsurance

$35 copayment

20% coinsurance

$35 copayment

20% coinsurance

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
20% coinsurance
20% coinsurance
Not covered
20% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Silver Select Silver NS INN Dep25
HIOS Plan ID: 78124NY0900010-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$1,650
$3,300
5% coinsurance
5% coinsurance
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$5 copayment
$35 copayment
$70 copayment
5% coinsurance
5% coinsurance
5% coinsurance
50% coinsurance
5% coinsurance

$35 copayment

5% coinsurance

$35 copayment

5% coinsurance

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

5% coinsurance
5% coinsurance
5% coinsurance
Not covered
5% coinsurance

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep29
HIOS Plan ID: 78124NY0890014
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment

$5 copayment
$35 copayment
$70 copayment

$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Gold Select Gold NS INN Dep25
HIOS Plan ID: 78124NY0890016
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Gold Benefits

How Does this Non-Standard

Product Compare?

$600
$1,200

$600
$1,200

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$4,000
$8,000
$25 copayment
$40 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,000 copayment
$150 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$35 copayment
$70 copayment
$750 copayment
$250 copayment
$40 copayment
50% coinsurance
$40 copayment

$40 copayment

$25 copayment

$40 copayment

$40 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

0% coinsurance
$25 copayment
$40 copayment
Not covered
$40 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep29
HIOS Plan ID: 78124NY0880008
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$60 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Excellus

Product Name: Platinum Select Platinum NS INN Dep25
HIOS Plan ID: 78124NY0880010
Metal Level: Platinum
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Platinum Benefits

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$6,350
$12,700
$15 copayment
$25 copayment
$0 copayment

$10 copayment
$30 copayment
$60 copayment
$500 copayment
$100 copayment
$60 copayment
20% coinsurance
$30 copayment

$5 copayment
$25 copayment
$50 copayment
$150 copayment
$75 copayment
$25 copayment
50% coinsurance
$25 copayment

$35 copayment

$15 copayment

$35 copayment

$25 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$15 copayment
$25 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0010001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies (PT/OT/ST)
Diagnostic & Routine Lab Services
Diagnostic & Routine Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness

Standard Silver Benefits

$2,000
$4,000
$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment
$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment
$50 copayment
$50 copayment
$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0020001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0030001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25
HIOS Plan ID: 25303NY0040001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0110001
Metal Level: Bronze

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Bronze Benefits
Deductible
$3,000
Individual Policy
$6,000
Family Policy
Maximum Out of Pocket
$6,350
Individual Policy
$12,700
Family Policy
PCP Visit
50% coinsurance
Specialist Visit
50% coinsurance
Preventive Care
0% coinsurance
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
50% coinsurance
Emergency Room
50% coinsurance
Urgent Care
50% coinsurance
Durable Medical Equipment
50% coinsurance
Covered Therapies (PT/OT/ST)
50% coinsurance
Diagnostic & Routine Lab Services
50% coinsurance
Diagnostic & Routine Imaging
50% coinsurance
Outpatient Surgery Services
50% coinsurance
Home Health Care Services
50% coinsurance
Outpatient Behavioral Health
50% coinsurance
Pediatric Basic Dental Care
50% coinsurance
Pediatric Vision Care
50% coinsurance
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001
Metal Level: Silver

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits
Deductible
$2,000
Individual Policy
$4,000
Family Policy
Maximum Out of Pocket
$5,500
Individual Policy
$11,000
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
30% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Silver Benefits, 200-250% FPL
Deductible
$1,200
Individual Policy
$2,400
Family Policy
Maximum Out of Pocket
$5,200
Individual Policy
$10,400
Family Policy
PCP Visit
$30 copayment
Specialist Visit
$50 copayment
Preventive Care
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,500 copayment
Emergency Room
$150 copayment
Urgent Care
$70 copayment
Durable Medical Equipment
25% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$50 copayment
Diagnostic & Routine Imaging
$50 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 150-200% FPL
Deductible
$250
Individual Policy
$500
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$9 copayment
Tier 1
$20 copayment
Tier 2
$40 copayment
Tier 3
Inpatient Services
$250 copayment
Emergency Room
$75 copayment
Urgent Care
$50 copayment
Durable Medical Equipment
10% coinsurance
Covered Therapies (PT/OT/ST)
$25 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$75 copayment
Home Health Care Services
$15 copayment
Outpatient Behavioral Health
$15 copayment
Pediatric Basic Dental Care
$15 copayment
Pediatric Vision Care
$15 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0140001-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Silver Benefits, 100-150% FPL
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$1,000
Individual Policy
$2,000
Family Policy
PCP Visit
$10 copayment
Specialist Visit
$20 copayment
Preventive Care
$0 copayment
Prescription Drug
$6 copayment
Tier 1
$15 copayment
Tier 2
$30 copayment
Tier 3
Inpatient Services
$100 copayment
Emergency Room
$50 copayment
Urgent Care
$30 copayment
Durable Medical Equipment
5% coinsurance
Covered Therapies (PT/OT/ST)
$15 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$25 copayment
Home Health Care Services
$10 copayment
Outpatient Behavioral Health
$10 copayment
Pediatric Basic Dental Care
$10 copayment
Pediatric Vision Care
$10 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0170001
Metal Level: Gold
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Standard Gold Benefits
Deductible
$600
Individual Policy
$1,200
Family Policy
Maximum Out of Pocket
$4,000
Individual Policy
$8,000
Family Policy
PCP Visit
$25 copayment
Specialist Visit
$40 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$35 copayment
Tier 2
$70 copayment
Tier 3
Inpatient Services
$1,000 copayment
Emergency Room
$150 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$40 copayment
Diagnostic & Routine Imaging
$40 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Fidelis Care

Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29
HIOS Plan ID: 25303NY0200001
Metal Level: Platinum

In-Network Benefits: Out-of-Network Benefits:

Benefit Description
Standard Platinum Benefits
Deductible
$0
Individual Policy
$0
Family Policy
Maximum Out of Pocket
$2,000
Individual Policy
$4,000
Family Policy
PCP Visit
$15 copayment
Specialist Visit
$35 copayment
Preventive Care
$0 copayment
Prescription Drug
$10 copayment
Tier 1
$30 copayment
Tier 2
$60 copayment
Tier 3
Inpatient Services
$500 copayment
Emergency Room
$100 copayment
Urgent Care
$60 copayment
Durable Medical Equipment
20% coinsurance
Covered Therapies (PT/OT/ST)
$30 copayment
Diagnostic & Routine Lab Services
$35 copayment
Diagnostic & Routine Imaging
$35 copayment
Outpatient Surgery Services
$100 copayment
Home Health Care Services
$30 copayment
Outpatient Behavioral Health
$30 copayment
Pediatric Basic Dental Care
$30 copayment
Pediatric Vision Care
$30 copayment
Wellness
Gym Membership Reimbursement

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$3,000
$6,000

$5,500
$11,000

$6,350
$12,700
50% coinsurance
50% coinsurance
0% coinsurance

$6,350
$12,700
$75 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

50% coinsurance

$75 coinsurance

50% coinsurance

$75 copayment

50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Bronze NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$5,500
$11,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$75 copayment
$75 copayment
$ copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$300 coinsurance
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0670001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$100 coinsurance
20% coinsurance
$75 coinsurance

$50 copayment

$75 coinsurance

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$75 copayment
$75 copayment
Not covered
$75 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy
Naturopathy
HIOS Plan ID: 71644NY0690001
Metal Level: Bronze
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Bronze Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$6,000
$12,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,500
$13,000
$0 copayment
$0 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$30 copayment
$0 copayment
$0 copayment
$0 copayment
$0 copayment
$75 copayment
$0 copayment
$0 copayment

$50 copayment

$0 copayment

$50 copayment

$0 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$0 copayment
$0 copayment
$0 copayment
Not covered
$0 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$75 coinsurance

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
20% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
20% copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayment
$75 copayment
$50 copayment
10% coinsurance
$25 copayment

$10 copayment
$20 copayment
$40 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$75 copayment
$15 copayment
$15 copayment
$15 copayment
$15 copayment

20% coinsurance
$25 copayment
$0 copayment
Not covered
$25 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep 25 Acupuncture
HIOS Plan ID: 71644NY0030002-06
Metal Level: Silver Cost Share Reduction, 100-150% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

100-150% FPL

How Does this Non-Standard

Product Compare?

$0
$0

$0
$0

$1,000
$2,000
$10 copayment
$20 copayment
$0 copayment

$500
$1,000
$0 copayment
$75 copayment
$0 copayment

$6 copayment
$15 copayment
$30 copayment
$100 copayment
$50 copayment
$30 copayment
5% coinsurance
$15 copayment

$10 copayment
$15 copayment
$30 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$35 copayment

$75 copayment

$35 copayment

$75 copayment

$25 copayment
$10 copayment
$10 copayment
$10 copayment
$10 copayment

20% coinsurance
$10 copayment
$0 copayment
Not covered
$10 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002
Metal Level: Silver
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits

How Does this Non-Standard

Product Compare?

$2,000
$4,000

$2,000
$4,000

$5,500
$11,000
$30 copayment
$50 copayment
$0 copayment

$6,350
$12,700
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1500 copayment
$150 copayment
$70 copayment
30% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

20% coinsurance
$30 copayment
$0 copayment
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-04
Metal Level: Silver Cost Share Reduction, 200-250% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

200-250% FPL

How Does this Non-Standard

Product Compare?

$1,200
$2,400

$2,000
$4,000

$5,200
$10,400
$30 copayment
$50 copayment
$0 copayment

$4,500
$9,000
$0 copayment
$75 copayment
$0 copayment

$10 copayment
$35 copayment
$70 copayment
$1,500 copayment
$150 copayment
$70 copayment
25% coinsurance
$30 copayment

$10 copayment
$35 copayment
$70 copayment
20% coinsurance
$250 copayment
$100 copayment
20% coinsurance
$30 copayment

$50 copayment

$75 copayment

$50 copayment

$75 copayment

$100 copayment
$30 copayment
$30 copayment
$30 copayment
$30 copayment

$30 copayment
20% coinsurance
Not covered
$30 copayment

Gym Membership
Reimbursement

Gym Membership
Reimbursement

Additional Non-Standard Benefits: Acupuncture

Plan Name: Health Republic Insurance

Product Name: Primary Select Silver NS INN Dep29 Acupuncture
HIOS Plan ID: 71644NY0130002-05
Metal Level: Silver Cost Share Reduction, 150-200% FPL
In-Network Benefits: Out-of-Network Benefits:
Benefit Description
Deductible
Individual Policy
Family Policy
Maximum Out of Pocket
Individual Policy
Family Policy
PCP Visit
Specialist Visit
Preventive Care
Prescription Drug
Tier 1
Tier 2
Tier 3
Inpatient Services
Emergency Room
Urgent Care
Durable Medical Equipment
Covered Therapies
(PT/OT/ST)
Diagnostic & Routine Lab
Services
Diagnostic & Routine
Imaging
Outpatient Surgery Services
Home Health Care Services
Outpatient Behavioral Health
Pediatric Basic Dental Care
Pediatric Vision Care
Wellness:
Gym Membership
Reimbursement

Standard Silver Benefits,

150-200% FPL

How Does this Non-Standard

Product Compare?

$250
$500

$0
$0

$2,000
$4,000
$15 copayment
$35 copayment
$0 copayment

$1,750
$3,500
$0 copayment
$75 copayment
$0 copayment

$9 copayment
$20 copayment
$40 copayment
$250 copayme