Marketplace ::Individual & Families::

Compare Plans 1 - 3 Plans Compared	Healthfirst Gold Leaf, ST, INN, Pediatric Dental, Dep25, Fitness & Wellness Rewards	Healthfirst Silver Leaf, ST, INN, Pediatric Dental, Dep25, Fitness & Wellness Rewards	Healthfirst Platinum Leaf, ST, INN, Pediatric Dental, Dep25, Fitness & Wellness Rewards
Plan Id	91237NY0020011	91237NY0020007	91237NY0020015
Metal Level	Gold	Silver	Platinum
Allows Health Savings Account	No	No	No
Monthly Premium	$649.77	$564.08	$815.09
Persons Covered	individual	individual	individual
Annual Deductible- Individual	$600	$2,000	$0
Annual Deductible- Family	$600 per person \| $1200 per group	$2000 per person \| $4000 per group	$0 per person \| $0 per group
Out of Pocket Maximum- Individual	$4,000	$6,750	$2,000
Out of Pocket Maximum- Family	$4000 per person \| $8000 per group	$6750 per person \| $13500 per group	$2000 per person \| $4000 per group
Out of Network Coverage	No	No	No
Specialist(s) Referral Required	No	No	No
Referral(s) Required	N/A	N/A	N/A
Design	Healthfirst Leaf Plans are health insurance plans that offer complete coverage, including: 10 essential health benefits (such as free preventive/annual checkups), maternity care, prescription drugs, hospital stays, emergency services, and more. All Healthfirst Leaf Plans include access to a large network of thousands of providers. No referrals required for: specialists, obstetric and gynecologic services, chiropractic services, outpatient mental health and substance abuse services, pediatric dental care, pediatric vision care (except from an ophthalmologist).	Healthfirst Leaf Plans are health insurance plans that offer complete coverage, including: 10 essential health benefits (such as free preventive/annual checkups), maternity care, prescription drugs, hospital stays, emergency services, and more. All Healthfirst Leaf Plans include access to a large network of thousands of providers. No referrals required for: specialists, obstetric and gynecologic services, chiropractic services, outpatient mental health and substance abuse services, pediatric dental care, pediatric vision care (except from an ophthalmologist).	Healthfirst Leaf Plans are health insurance plans that offer complete coverage, including: 10 essential health benefits (such as free preventive/annual checkups), maternity care, prescription drugs, hospital stays, emergency services, and more. All Healthfirst Leaf Plans include access to a large network of thousands of providers. No referrals required for: specialists, obstetric and gynecologic services, chiropractic services, outpatient mental health and substance abuse services, pediatric dental care, pediatric vision care (except from an ophthalmologist).

Quality Measure	Rating	Rating	Rating
Medical Care
Plan Administration
Member Experience
Overall Quality Rating

IN-NETWORK
Out of Network

Emergency Services

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
Emergency Room Services Help tooltip	$150.00 Copay after deductible	$250.00 Copay after deductible	$100.00
Emergency Transportation/Ambulance Help tooltip	$150.00 Copay after deductible	$150.00 Copay after deductible	$100.00
Urgent Care Centers or Facilities Help tooltip	$60.00 Copay after deductible	$70.00 Copay after deductible	$55.00

Other Services

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
Chemotherapy Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Family Planning Services Help tooltip	No Charge	No Charge	No Charge
Diabetic Equipment and Supplies Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Second Opinion Help tooltip	$40.00 Copay after deductible	$50.00 Copay after deductible	$35.00
Transplant Help tooltip	$1100.00 Copay after deductible	$1600.00 Copay after deductible	$600.00

Hospitalization

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
Inpatient Physician and Surgical Services Help tooltip	$100.00 Copay after deductible	$100.00 Copay after deductible	$100.00
Skilled Nursing Facility Help tooltip	$1000.00 Copay per Stay after deductible	$1500.00 Copay per Stay after deductible	$500.00 Copay per Stay
Delivery and All Inpatient Services for Maternity Care Help tooltip	$1100.00 Copay after deductible	$1600.00 Copay after deductible	$600.00
Inpatient Hospital Services (e.g., Hospital Stay) Help tooltip	$1000.00 Copay per Stay after deductible	$1500.00 Copay per Stay after deductible	$500.00 Copay per Stay

Prescription Drugs

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
Generic Drugs Help tooltip	$10.00	$10.00	$10.00
Preferred Brand Drugs Help tooltip	$35.00	$35.00	$30.00
Non-Preferred Brand Drugs Help tooltip	$70.00	$70.00	$60.00

Outpatient Services

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
Specialist Visit Help tooltip	$40.00 Copay after deductible	$50.00 Copay after deductible	$35.00
Home Health Care Services Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Outpatient Surgery Physician/Surgical Services Help tooltip	$100.00 Copay after deductible	$100.00 Copay after deductible	$100.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Help tooltip	$100.00 Copay after deductible	$100.00 Copay after deductible	$100.00
Primary Care Visit to Treat an Injury or Illness Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Other Practitioner Office Visit (Nurse, Physician Assistant) Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00

Mental Health and Substance Abuse Services

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
Mental/Behavioral Health Inpatient Services Help tooltip	$1000.00 Copay per Stay after deductible	$1500.00 Copay per Stay after deductible	$500.00 Copay per Stay
Applied Behavior Analysis Based Therapies Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Substance Abuse Disorder Outpatient Services Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Mental/Behavioral Health Outpatient Services Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Substance Abuse Disorder Inpatient Services Help tooltip	$1000.00 Copay per Stay after deductible	$1500.00 Copay per Stay after deductible	$500.00 Copay per Stay

Preventive and Wellness Services and Chronic Disease Management

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
Gym Membership Reimbursement Help tooltip	$0.00	$0.00	$0.00
Preventive Care/Screening/Immunization Help tooltip	No Charge	No Charge	No Charge
Well Baby Visits and Care Help tooltip	No Charge	No Charge	No Charge
Prenatal and Postnatal Care Help tooltip	No Charge	No Charge	No Charge

Rehabilitative and Habilitative Services and Devices

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
Chiropractic Care Help tooltip	$40.00 Copay after deductible	$50.00 Copay after deductible	$35.00
Inpatient Rehabilitation Services Help tooltip	$1000.00 Copay after deductible	$1500.00 Copay after deductible	$500.00
Prosthetic Devices Help tooltip	20.00% Coinsurance after deductible	30.00% Coinsurance after deductible	10.00%
Outpatient Rehabilitation Services Help tooltip	$30.00 Copay after deductible	$30.00 Copay after deductible	$25.00
Durable Medical Equipment Help tooltip	20.00% Coinsurance after deductible	30.00% Coinsurance after deductible	10.00%

Laboratory Outpatient and Professional Services

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
X-rays and Diagnostic Imaging Help tooltip	$40.00 Copay after deductible	$50.00 Copay after deductible	$35.00
Imaging (CT/PET Scans, MRIs) Help tooltip	$40.00 Copay after deductible	$50.00 Copay after deductible	$35.00
Laboratory Outpatient and Professional Services Help tooltip	$40.00 Copay after deductible	$50.00 Copay after deductible	$35.00

Pediatric Vision

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
Eye Glasses for Children Help tooltip	20.00% Coinsurance after deductible	30.00% Coinsurance after deductible	10.00%
Routine Eye Exam for Children Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Contact Lenses for Children Help tooltip	20.00% Coinsurance after deductible	30.00% Coinsurance after deductible	10.00%

Pediatric Dental Care

Benefit	In Network Cost Share	In Network Cost Share	In Network Cost Share
Orthodontia - Child Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Dental Check-Up for Children Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Major Dental Care - Child Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00
Basic Dental Care - Child Help tooltip	$25.00 Copay after deductible	$30.00 Copay after deductible	$15.00