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		MVP Premier Plus Bronze 3 HDHP, Expanded Bronze, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, HSA, Preferred Facilities, Preventive Rx, Telemedicine, Wellness

Price Per Month	$590.00	Metal	Bronze	Overall Quality Rating	Quality Details
Maximum Out of Pocket	$7,100 / $7100 per person \| $14200 per group	Out-of-Network Coverage	No	Allows Health Savings Account	Yes
Plan Id	56184NY0200007	Persons Covered	individual	Deductible	$6,500 / $6500 per person \| $13000 per group
Specialist(s) Referral Required No

Design	This is a qualified High Deductible Health Plan (HDHP) which can be paired with an MVP Health Savings Account to help offset out-of-pocket costs. Preventive Drugs are not subject to the deductible. Covered in full preventive care services, per recommended age and gender guidelines. Families are eligible for $1,000 for out-of-area coverage for Dependent Child Members up to age 26. At MVP Preferred Providers, lab, radiology, and ambulatory/outpatient surgery services received will be covered in full or after the deductible, if applicable. Access to MVP's telemedicine services, including 24/7 urgent and emergency care, behavioral health, pscyhiatry, physical therapy, and more. Acupuncture Services, 12 visits per plan year. 20% savings on CVS-branded health related items. Plan includes Pediatric Vision Exams and Eyewear. $600 WellBeing Reimbusement. No referrals are required. The Deductible (if applicable) and Out-of-Pocket Maximum are Embedded

Design

This is a qualified High Deductible Health Plan (HDHP) which can be paired with an MVP Health Savings Account to help offset out-of-pocket costs. Preventive Drugs are not subject to the deductible. Covered in full preventive care services, per recommended age and gender guidelines. Families are eligible for $1,000 for out-of-area coverage for Dependent Child Members up to age 26. At MVP Preferred Providers, lab, radiology, and ambulatory/outpatient surgery services received will be covered in full or after the deductible, if applicable. Access to MVP's telemedicine services, including 24/7 urgent and emergency care, behavioral health, pscyhiatry, physical therapy, and more. Acupuncture Services, 12 visits per plan year. 20% savings on CVS-branded health related items. Plan includes Pediatric Vision Exams and Eyewear. $600 WellBeing Reimbusement. No referrals are required. The Deductible (if applicable) and Out-of-Pocket Maximum are Embedded

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	Out of Network Cost Share	Subject to Deductible	Description
Transplant	30.00% Coinsurance 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.
Telemedicine	No Charge	100.00%	Online internet consultations with a MVP approved telemedicine vendor
Second Opinion	$50.00 Copay after deductible	100.00%	A second medical opinion by an appropriate specialist or surgeon.
Acupuncture	50.00% Coinsurance after deductible	100.00%	Acupuncture is a method of treatment derived from ancient Chinese Medicine
Chemotherapy	$50.00 Copay 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	$30.00 Copay after deductible	100.00%
Family Planning Services	No Charge	100.00%	Counseling on the use of contraceptives, sterilization procedures, and related topics.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Urgent Care Centers or Facilities	$50.00 Copay after deductible	$50.00 Copay after deductible	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	$500.00 Copay after deductible	$500.00 Copay after deductible	Healthcare services you get in an emergency room.
Emergency Transportation/Ambulance	$500.00 Copay after deductible	$500.00 Copay after deductible	Ambulance services for an emergency medical condition.

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	Not Applicable	Not Applicable	Get reimbursed up to $600 per contract, per calendar year for expenses associated with activities, tools, and apps that enhance your overall well-being with MVP’s Well-Being Reimbursement.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
X-rays and Diagnostic Imaging	$50.00 Copay after deductible	100.00%	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Laboratory Outpatient and Professional Services	$50.00 Copay after deductible	100.00%	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.
Imaging (CT/PET Scans, MRIs)	$150.00 Copay after deductible	100.00%	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Prosthetic Devices	50.00% Coinsurance after deductible	100.00%	One external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices)
Outpatient Rehabilitation Services	$50.00 Copay after deductible	100.00%	54 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Inpatient Rehabilitation Services	30.00% Coinsurance 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.
Chiropractic Care	$50.00 Copay after deductible	100.00%	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	50.00% Coinsurance 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.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Substance Abuse Disorder Outpatient Services	$30.00 Copay after deductible	100.00%	Also includes 20 visits per year for family counseling.
Mental/Behavioral Health Inpatient Services	30.00% Coinsurance after deductible	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	$30.00 Copay after deductible	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.
Substance Abuse Disorder Inpatient Services	30.00% Coinsurance 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.
Applied Behavior Analysis Based Therapies	$30.00 Copay after deductible	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

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Home Health Care Services	$50.00 Copay 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)	$30.00 Copay after deductible	100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	$100.00 Copay after deductible	100.00%
Outpatient Surgery Physician/Surgical Services	$100.00 Copay 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	$30.00 Copay after deductible	100.00%	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.
Specialist Visit	$50.00 Copay after deductible	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.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Non-Preferred Brand Drugs	$90.00 Copay 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	$45.00 Copay 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.
Specialty Drugs	$90.00 Copay 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.
Generic Drugs	$10.00 Copay after deductible	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.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Routine Eye Exam for Children	$50.00 Copay after deductible	100.00%	Emergency, preventive and routine vision care for children.
Eye Glasses for Children	50.00% Coinsurance after deductible	100.00%	One prescribed lenses & frames in a 12-month period.
Contact Lenses for Children	50.00% Coinsurance after deductible	100.00%	Standard prescription contact lenses once in any twelve (12) month period.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Skilled Nursing Facility	30.00% Coinsurance 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	30.00% Coinsurance 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)	30.00% Coinsurance 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	30.00% Coinsurance after deductible	100.00%	Surgical services performed by a physician or surgeon in an inpatient facility.

		MVP Premier Plus Bronze 3 HDHP, Expanded Bronze, NS, INN, NY Individual On Exchange HMO, Dep25, Acupuncture, HSA, Preferred Facilities, Preventive Rx, Telemedicine, Wellness

Price Per Month	$590.00	Metal	Bronze	Overall Quality Rating
Quality Measure	Medical Care	Rating		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.
Quality Measure	Plan Administration	Rating		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	Member Experience	Rating		Description	Based on member satisfaction surveys about their health care, doctors, and ease of getting appointments and services.
Maximum Out of Pocket	$7,100 / $7100 per person \| $14200 per group	Out-of-Network Coverage	No	Allows Health Savings Account	Yes
Plan Id	56184NY0200007	Persons Covered	individual	Deductible	$6,500 / $6500 per person \| $13000 per group
Specialist(s) Referral Required	No

Design	This is a qualified High Deductible Health Plan (HDHP) which can be paired with an MVP Health Savings Account to help offset out-of-pocket costs. Preventive Drugs are not subject to the deductible. Covered in full preventive care services, per recommended age and gender guidelines. Families are eligible for $1,000 for out-of-area coverage for Dependent Child Members up to age 26. At MVP Preferred Providers, lab, radiology, and ambulatory/outpatient surgery services received will be covered in full or after the deductible, if applicable. Access to MVP's telemedicine services, including 24/7 urgent and emergency care, behavioral health, pscyhiatry, physical therapy, and more. Acupuncture Services, 12 visits per plan year. 20% savings on CVS-branded health related items. Plan includes Pediatric Vision Exams and Eyewear. $600 WellBeing Reimbusement. No referrals are required. The Deductible (if applicable) and Out-of-Pocket Maximum are Embedded

Design

Other Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Transplant	30.00% Coinsurance 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.
Telemedicine	No Charge	100.00%	Online internet consultations with a MVP approved telemedicine vendor
Second Opinion	$50.00 Copay after deductible	100.00%	A second medical opinion by an appropriate specialist or surgeon.
Acupuncture	50.00% Coinsurance after deductible	100.00%	Acupuncture is a method of treatment derived from ancient Chinese Medicine
Chemotherapy	$50.00 Copay 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	$30.00 Copay after deductible	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
Urgent Care Centers or Facilities	$50.00 Copay after deductible	$50.00 Copay after deductible	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	$500.00 Copay after deductible	$500.00 Copay after deductible	Healthcare services you get in an emergency room.
Emergency Transportation/Ambulance	$500.00 Copay after deductible	$500.00 Copay 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
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	Not Applicable	Not Applicable	Get reimbursed up to $600 per contract, per calendar year for expenses associated with activities, tools, and apps that enhance your overall well-being with MVP’s Well-Being Reimbursement.

Laboratory Outpatient and Professional Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
X-rays and Diagnostic Imaging	$50.00 Copay after deductible	100.00%	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Laboratory Outpatient and Professional Services	$50.00 Copay after deductible	100.00%	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.
Imaging (CT/PET Scans, MRIs)	$150.00 Copay after deductible	100.00%	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition

Rehabilitative and Habilitative Services and Devices

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Prosthetic Devices	50.00% Coinsurance after deductible	100.00%	One external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices)
Outpatient Rehabilitation Services	$50.00 Copay after deductible	100.00%	54 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery.
Inpatient Rehabilitation Services	30.00% Coinsurance 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.
Chiropractic Care	$50.00 Copay after deductible	100.00%	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	50.00% Coinsurance 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.

Mental Health and Substance Abuse Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Substance Abuse Disorder Outpatient Services	$30.00 Copay after deductible	100.00%	Also includes 20 visits per year for family counseling.
Mental/Behavioral Health Inpatient Services	30.00% Coinsurance after deductible	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	$30.00 Copay after deductible	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.
Substance Abuse Disorder Inpatient Services	30.00% Coinsurance 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.
Applied Behavior Analysis Based Therapies	$30.00 Copay after deductible	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

Outpatient Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Home Health Care Services	$50.00 Copay 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)	$30.00 Copay after deductible	100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	$100.00 Copay after deductible	100.00%
Outpatient Surgery Physician/Surgical Services	$100.00 Copay 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	$30.00 Copay after deductible	100.00%	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.
Specialist Visit	$50.00 Copay after deductible	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.

Prescription Drugs

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Non-Preferred Brand Drugs	$90.00 Copay 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	$45.00 Copay 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.
Specialty Drugs	$90.00 Copay 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.
Generic Drugs	$10.00 Copay after deductible	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.

Pediatric Vision

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Routine Eye Exam for Children	$50.00 Copay after deductible	100.00%	Emergency, preventive and routine vision care for children.
Eye Glasses for Children	50.00% Coinsurance after deductible	100.00%	One prescribed lenses & frames in a 12-month period.
Contact Lenses for Children	50.00% Coinsurance after deductible	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
Skilled Nursing Facility	30.00% Coinsurance 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	30.00% Coinsurance 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)	30.00% Coinsurance 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	30.00% Coinsurance after deductible	100.00%	Surgical services performed by a physician or surgeon in an inpatient facility.

Plan Documents

Customer Service	mvphealthcare.com
Summary of Benefits and Coverage	https://www.mvphealthcare.com/ny/ns/indiv/bronze/
Prescription Drug List	https://www.mvphealthcare.com/members/prescription-benefits/
Provider Network	https://www.mvphealthcare.com/members/find-a-doctor
Plan Brochure	https://www.mvphealthcare.com
Payment Information	https://www.mvphealthcare.com/members/make-a-payment/

Plan Details