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		EmblemHealth Bold, Silver, NS, Millennium Network, INN, Family Dental & Vision, Dep25.

You Pay

$383.05

Price Per Month	$659.05	Metal	Silver	Overall Quality Rating	Quality Details
Maximum Out of Pocket	$6,500 / $6500 per person \| $13000 per group	Out-of-Network Coverage	No	Allows Health Savings Account	No
Plan Id	88582NY4650001	Persons Covered	individual	Deductible	$6,500 / $6500 per person \| $13000 per group
Specialist(s) Referral Required Yes		Referral(s) Required

Design	All plans, except Gold Premier, require a written referral from your PCP before receiving Specialist care. The plans include Telemedicine, with physician consultations and dietician services. The Telemedicine benefit is free for all of the metal plans. Non-standard plans also include adult dental and vision.

Click on the benefit categories below to learn more about this plan's covered benefits and services. To see a full list of the benefits and services, visit the "Summary of Benefits" link under "Plan Documents" at the bottom of this page.

Prescription Drugs

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Specialty Drugs	No Charge after deductible	100.00%	Specialty drugs are used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. The drugs are often self-injected or administered in a physician's office or through home health services.
Non-Preferred Brand Drugs	No Charge after deductible	100.00%	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Non-preferred drugs may or may not be included on a plan's covered drug list or formulary and have higher cost-share.
Preferred Brand Drugs	No Charge after deductible	100.00%	Brand drugs are sold by a drug company under a specific name or trademark and is protected by a patent. Preferred drugs are included on a plan's covered drug list or formulary.
Generic Drugs	$15.00	100.00%	A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.

Mental Health and Substance Abuse Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Substance Abuse Disorder Inpatient Services	No Charge after deductible	100.00%	Diagnosis and treatment of alcoholism and/or substance use and/or dependency in an inpatient setting. This includes coverage for detoxification and/or rehabilitation services as a consequence of chemical use and/or substance use.
Substance Abuse Disorder Outpatient Services	$50.00	100.00%	Also includes 20 visits per year for family counseling.
Mental/Behavioral Health Inpatient Services	No Charge after deductible	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	$50.00	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.
Applied Behavior Analysis Based Therapies	$50.00	100.00%	Design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis

Other Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Transplant	No Charge after deductible	100.00%	Transplants determined to be nonexperimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome. NOTE: Cost-share shown is the combined amount, including both the surgical fee and the Inpatient cost-share.
Second Opinion	No Charge after deductible	100.00%	A second medical opinion by an appropriate specialist or surgeon.
Acupuncture	No Charge	100.00%
Chemotherapy	No Charge after deductible	100.00%	Chemotherapy in an outpatient facility or in a Health Care Professional's office. Orally-administered anti-cancer drugs are covered under the prescription drug benefit.
Diabetic Equipment and Supplies	$50.00	100.00%
Family Planning Services	No Charge	100.00%	Counseling on the use of contraceptives, sterilization procedures, and related topics.

Emergency Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Urgent Care Centers or Facilities	$75.00	100.00%	A licensed facility (except Hospitals) that provides care for an illness, injury or condition serious enough to require care right away, but not so severe as to require emergency room care.
Emergency Room Services	No Charge after deductible	No Charge after deductible	Healthcare services you get in an emergency room.
Emergency Transportation/Ambulance	No Charge after deductible	No Charge after deductible	Ambulance services for an emergency medical condition.

Preventive and Wellness Services and Chronic Disease Management

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Well Baby Visits and Care	No Charge	100.00%	Routine doctor visits for comprehensive preventive health services that occur when a baby is young.
Prenatal and Postnatal Care	No Charge	100.00%	Healthcare for expectant mothers before and after the birth of their child.
Preventive Care/Screening/Immunization	No Charge	100.00%	Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Gym Membership Reimbursement	No Charge	No Charge	Up to $200 per 6 month period; up to $100 per 6 month period for spouse

Laboratory Outpatient and Professional Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
X-rays and Diagnostic Imaging	No Charge after deductible	100.00%	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Laboratory Outpatient and Professional Services	$70.00	100.00%	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.
Imaging (CT/PET Scans, MRIs)	No Charge after deductible	100.00%	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition

Adult Dental Care

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Basic Dental Care - Adult	$50.00	100.00%	Cleanings and Exams
Routine Dental Services (Adult)	$50.00	100.00%

Outpatient Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Home Health Care Services	No Charge after deductible	100.00%	Each visit of up to four hours by a home health aide is one visit.
Other Practitioner Office Visit (Nurse, Physician Assistant)	$50.00	100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	No Charge after deductible	100.00%
Outpatient Surgery Physician/Surgical Services	No Charge after deductible	100.00%	Surgical services performed by a physician or surgeon in an outpatient facility.
Primary Care Visit to Treat an Injury or Illness	$50.00	100.00%	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.
Specialist Visit	$70.00	100.00%	Visits to a physician to diagnose, manage, prevent or treat certain types of symptoms and conditions related to a specific disease or condition.

Rehabilitative and Habilitative Services and Devices

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Outpatient Rehabilitation Services	No Charge after deductible	100.00%	60 visits per condition per year combined.
Prosthetic Devices	No Charge after deductible	100.00%	External: devices that are worn externally and that temporarily or permanently replace all or part of an external body part that has been lost or damaged because of an injury or disease. One (1) prosthetic device, per limb, per lifetime, and the cost of repair and replacement of the prosthetic devices and its parts. Internal: implanted devices and special appliances that improve or restore the function of an internal body part which has been removed or damaged due to disease or injury
Chiropractic Care	$70.00	100.00%	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	No Charge after deductible	100.00%	Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Inpatient Rehabilitation Services	No Charge after deductible	100.00%	Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services consist of physical therapy, occupational therapy, and speech therapy in an inpatient setting.

Pediatric Dental Care

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Major Dental Care - Child	No Charge after deductible	100.00%	Services, including procedures for treatment of diseased pulp chambers and pulp canals, where Hospitalization is not required, removable complete or partial dentures, including six (6) months follow-up care; and additional services include insertion of identification slips, repairs, relines and rebases and treatment of cleft palate.
Orthodontia - Child	No Charge after deductible	100.00%	Orthodontics used to help restore oral structures to health and function and to treat serious medical conditions for children.
Basic Dental Care - Child	$50.00	100.00%	One dental exam & cleaning every 6 months and x-rays (full mouth and panoramic) every 36 months.
Dental Check-Up for Children	No Charge	100.00%	Procedures which help prevent oral disease from occurring.

Adult Vision Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Routine Eye Exam (Adult)	No Charge	100.00%

Pediatric Vision

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Routine Eye Exam for Children	No Charge	100.00%	Emergency, preventive and routine vision care for children.
Eye Glasses for Children	30.00%	100.00%	One prescribed lenses & frames in a 12-month period.
Contact Lenses for Children	30.00%	100.00%	Standard prescription contact lenses once in any twelve (12) month period.

Hospitalization

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Skilled Nursing Facility	No Charge after deductible	100.00%	A facility that performs skilled nursing care and rehabilitation services provided on a continuous, daily basis.
Delivery and All Inpatient Services for Maternity Care	No Charge after deductible	100.00%	Delivery and inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery.
Inpatient Hospital Services (e.g., Hospital Stay)	No Charge after deductible	100.00%	Health care you get when you're admitted as a patient to a health care facility, like a hospital or skilled nursing facility.
Inpatient Physician and Surgical Services	No Charge after deductible	100.00%	Surgical services performed by a physician or surgeon in an inpatient facility.

Plan Documents

		EmblemHealth Bold, Silver, NS, Millennium Network, INN, Family Dental & Vision, Dep25.