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HealthPlus Gatekeeper X, Bronze, ST, INN, Individual Network, Dep 25, Pediatric Dental
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Price Per Month |
$648.38
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Metal |
Bronze
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Overall Quality Rating |
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Quality Measure |
Member Experience |
Rating |
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Description |
Based on member satisfaction surveys about their health care, doctors, and ease of getting appointments and services. |
Quality Measure |
Plan Administration |
Rating |
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Description |
Based on certain measures of how well a plan is run, including customer service, access to needed information, and network providers ordering appropriate testing and treatment. |
Quality Measure |
Medical Care |
Rating |
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Description |
Based on the plan's network providers improving or maintaining the health of its members with regular screenings, tests, vaccines, and monitoring of some conditions. |
Maximum Out of Pocket |
$8,700 / $8700 per person | $17400 per group
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Out-of-Network Coverage |
No
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Allows Health Savings Account |
No
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Plan Id |
41046NY0010038
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Persons Covered |
individual |
Deductible |
$4,700 / $4700 per person | $9400 per group
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Specialist(s) Referral Required |
Yes |
Referral(s) Required |
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Design |
Empire proudly serves members in its New York service area. Our provider network gives access to leading doctors and hospitals throughout our New York service area. The network includes primary care physicians who are committed to transforming their practices to a patient-centered model of care. All Empire plans require referrals for specialist care. |
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.
Benefit |
In Network Cost Share
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Out of Network Cost Share |
Subject to Deductible |
Description |
Substance Abuse Disorder Inpatient Services
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$1500.00 Copay per Stay after deductible
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100.00%
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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.
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Mental/Behavioral Health Inpatient Services
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$1500.00 Copay per Stay after deductible
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100.00%
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Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
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Applied Behavior Analysis Based Therapies
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$50.00 Copay after deductible
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100.00%
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3 office visit with copayment not subject to deductible. Subsequent visits with Copayment after Deductible. Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services
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Mental/Behavioral Health Outpatient Services
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$50.00 Copay after deductible
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100.00%
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3 office visit with copayment not subject to deductible. Subsequent visits with Copayment after Deductible. Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services
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Substance Abuse Disorder Outpatient Services
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$50.00 Copay after deductible
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100.00%
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3 office visit with copayment not subject to deductible. Subsequent visits with Copayment after Deductible. Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services
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Benefit |
In Network Cost Share
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Out of Network Cost Share |
Subject to Deductible |
Description |
Urgent Care Centers or Facilities
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$75.00 Copay after deductible
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100.00%
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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.
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Emergency Room Services
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$500.00 Copay after deductible
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$500.00 Copay after deductible
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Healthcare services you get in an emergency room.
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Emergency Transportation/Ambulance
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$300.00 Copay after deductible
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$300.00 Copay after deductible
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Ambulance services for an emergency medical condition.
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Benefit |
In Network Cost Share
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Out of Network Cost Share |
Subject to Deductible |
Description |
Well Baby Visits and Care
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No Charge
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100.00%
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Routine doctor visits for comprehensive preventive health services that occur when a baby is young.
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Gym Membership Reimbursement
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No Charge
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100.00%
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Partial reimbursement for facility fees every 6 months if member attains at least 50 visits.
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Prenatal and Postnatal Care
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No Charge
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100.00%
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Healthcare for expectant mothers before and after the birth of their child.
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Preventive Care/Screening/Immunization
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No Charge
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100.00%
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You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
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Benefit |
In Network Cost Share
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Out of Network Cost Share |
Subject to Deductible |
Description |
X-rays and Diagnostic Imaging
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$75.00 Copay after deductible
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100.00%
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X-rays and other technologies that doctors use in the diagnosis of a medical condition
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Imaging (CT/PET Scans, MRIs)
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$175.00 Copay after deductible
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100.00%
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Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition
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Laboratory Outpatient and Professional Services
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$50.00 Copay after deductible
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100.00%
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Professional fees and services associated with laboratory work for diagnostic and treatment purposes.
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Benefit |
In Network Cost Share
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Out of Network Cost Share |
Subject to Deductible |
Description |
Home Health Care Services
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$50.00 Copay after deductible
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100.00%
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Each visit of up to four hours by a home health aide is one visit.
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Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
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$150.00 Copay after deductible
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100.00%
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Outpatient Surgery Physician/Surgical Services
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$150.00 Copay after deductible
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100.00%
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Surgical services performed by a physician or surgeon in an outpatient facility.
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Other Practitioner Office Visit (Nurse, Physician Assistant)
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$50.00 Copay after deductible
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100.00%
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3 office visit with copayment not subject to deductible. Subsequent visits with Copayment after Deductible. Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services
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Primary Care Visit to Treat an Injury or Illness
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$50.00 Copay after deductible
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100.00%
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3 office visit with copayment not subject to deductible. Subsequent visits with Copayment after Deductible. Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services
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Specialist Visit
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$75.00 Copay after deductible
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100.00%
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3 office visit with copayment not subject to deductible. Subsequent visits with Copayment after Deductible. Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services
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Benefit |
In Network Cost Share
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Out of Network Cost Share |
Subject to Deductible |
Description |
Basic Dental Care - Child
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$50.00 Copay after deductible
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100.00%
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One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.
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Orthodontia - Child
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$50.00 Copay after deductible
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100.00%
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Orthodontics used to help restore oral structures to health and function and to treat serious medical conditions for children.
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Major Dental Care - Child
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$50.00 Copay after deductible
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100.00%
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Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery
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Dental Check-Up for Children
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$50.00 Copay after deductible
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100.00%
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Procedures which help prevent oral disease from occurring.
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Benefit |
In Network Cost Share
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Out of Network Cost Share |
Subject to Deductible |
Description |
Outpatient Rehabilitation Services
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$50.00 Copay after deductible
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100.00%
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60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery. Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care Professional’s office.
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Durable Medical Equipment
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50.00% Coinsurance after deductible
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100.00%
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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.
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Inpatient Rehabilitation Services
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$1500.00 Copay after deductible
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100.00%
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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.
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Chiropractic Care
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$75.00 Copay after deductible
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100.00%
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3 office visit with copayment not subject to deductible. Subsequent visits with Copayment after Deductible. Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services
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Prosthetic Devices
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50.00% Coinsurance after deductible
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100.00%
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1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).
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Benefit |
In Network Cost Share
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Out of Network Cost Share |
Subject to Deductible |
Description |
Family Planning Services
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No Charge
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100.00%
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Counseling on the use of contraceptives, sterilization procedures, and related topics.
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Second Opinion
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$75.00 Copay after deductible
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100.00%
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3 office visit with copayment not subject to deductible. Subsequent visits with Copayment after Deductible. Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services
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Transplant
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$1650.00 Copay after deductible
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100.00%
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We Cover only those transplants determined to be non-experimental and non-investigational. Covered transplants include but are not limited to kidney, corneal, liver, heart, pancreas, and lung transplants; and bone marrow transplants.
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Chemotherapy
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$50.00 Copay after deductible
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100.00%
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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.
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Diabetic Equipment and Supplies
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$50.00 Copay after deductible
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100.00%
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Benefit |
In Network Cost Share
|
Out of Network Cost Share |
Subject to Deductible |
Description |
Generic Drugs
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$10.00 Copay after deductible
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100.00%
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A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.
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Non-Preferred Brand Drugs
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$70.00 Copay after deductible
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100.00%
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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.
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Preferred Brand Drugs
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$35.00 Copay after deductible
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100.00%
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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.
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Specialty Drugs
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$70.00 Copay after deductible
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100.00%
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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.
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Benefit |
In Network Cost Share
|
Out of Network Cost Share |
Subject to Deductible |
Description |
Inpatient Hospital Services (e.g., Hospital Stay)
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$1500.00 Copay per Stay after deductible
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100.00%
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Health care you get when you're admitted as a patient to a health care facility, like a hospital or skilled nursing facility.
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Inpatient Physician and Surgical Services
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$150.00 Copay after deductible
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100.00%
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Surgical services performed by a physician or surgeon in an inpatient facility.
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Skilled Nursing Facility
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$1500.00 Copay per Stay after deductible
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100.00%
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A facility that performs skilled nursing care and rehabilitation services provided on a continuous, daily basis.
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Delivery and All Inpatient Services for Maternity Care
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$1650.00 Copay after deductible
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100.00%
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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.
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Benefit |
In Network Cost Share
|
Out of Network Cost Share |
Subject to Deductible |
Description |
Routine Eye Exam for Children
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$50.00 Copay after deductible
|
100.00%
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Emergency, preventive and routine vision care for children.
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Eye Glasses for Children
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50.00% Coinsurance after deductible
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100.00%
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One prescribed lenses & frames in a 12-month period.
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Contact Lenses for Children
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50.00% Coinsurance after deductible
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100.00%
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Standard prescription contact lenses once in any twelve (12) month period.
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Customer Service |
http://www.empireblue.com
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Summary of Benefits and Coverage |
https://www.sbc.anthem.com/dps/ccd6R9C
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Prescription Drug List |
https://www.empireblue.com/EBSSelectdrugtier3
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Provider Network |
https://www.empireblue.com/find-care/?alphaprefix=VFG
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Plan Brochure |
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Payment Information |
https://payment.anthem.com/sales/payment/shopper/home?state=NY
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