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		Anthem Gatekeeper X, Bronze, ST, INN, Individual Network, Dep 25, Pediatric Dental

Price Per Month	$714.04	Metal	Bronze	Overall Quality Rating	Quality Details
Maximum Out of Pocket	$9,450 / $9450 per person \| $18900 per group	Out-of-Network Coverage	No	Allows Health Savings Account	No
Plan Id	41046NY0010038	Persons Covered	individual	Deductible	$4,600 / $4600 per person \| $9200 per group
Specialist(s) Referral Required Yes		Referral(s) Required	All specialists require referral with the exception of OB/GYN

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.

Mental Health and Substance Abuse Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Mental/Behavioral Health Outpatient Services	$50.00 Copay after deductible	100.00%	1st 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
Substance Abuse Disorder Outpatient Services	$50.00 Copay after deductible	100.00%	Also includes 20 visits per year for family counseling.
Mental/Behavioral Health Inpatient Services	$1500.00 Copay per Stay after deductible	100.00%	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Substance Abuse Disorder Inpatient Services	$1500.00 Copay per Stay 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	$50.00 Copay after deductible	100.00%	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

Outpatient Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Other Practitioner Office Visit (Nurse, Physician Assistant)	$50.00 Copay after deductible	100.00%	1st 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
Primary Care Visit to Treat an Injury or Illness	$50.00 Copay after deductible	100.00%	1st 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
Specialist Visit	$75.00	100.00%	1st 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
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.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	$150.00 Copay after deductible	100.00%
Outpatient Surgery Physician/Surgical Services	$150.00 Copay after deductible	100.00%	Surgical services performed by a physician or surgeon in an outpatient facility.

Other Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Second Opinion	$75.00 Copay after deductible	100.00%	1st 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
Transplant	$1650.00 Copay after deductible	100.00%	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.
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	$50.00 Copay after deductible	100.00%
Family Planning Services	No Charge	100.00%	Counseling on the use of contraceptives, sterilization procedures, and related topics.

Pediatric Dental Care

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Basic Dental Care - Child	$50.00 Copay after deductible	100.00%	One dental exam & cleaning every 6 months, x-rays (full mouth and panoramic) every 36 months, simple extractions and fillings.
Orthodontia - Child	$50.00 Copay after deductible	100.00%	Orthodontics used to help restore oral structures to health and function and to treat serious medical conditions for children.
Major Dental Care - Child	$50.00 Copay after deductible	100.00%	Major Dental Care includes Endodontics, Periodontics, Prosthodontics and Oral Surgery
Dental Check-Up for Children	$50.00 Copay after deductible	100.00%	Procedures which help prevent oral disease from occurring.

Rehabilitative and Habilitative Services and Devices

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Outpatient Rehabilitation Services	$50.00 Copay after deductible	100.00%	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.
Inpatient Rehabilitation Services	$1500.00 Copay 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	$75.00 Copay after deductible	100.00%	1st 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
Prosthetic Devices	50.00% Coinsurance after deductible	100.00%	1 external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices).
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.

Hospitalization

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Inpatient Physician and Surgical Services	$150.00 Copay after deductible	100.00%	Surgical services performed by a physician or surgeon in an inpatient facility.
Skilled Nursing Facility	$1500.00 Copay per Stay 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	$1650.00 Copay 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)	$1500.00 Copay per Stay 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.

Laboratory Outpatient and Professional Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
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.
X-rays and Diagnostic Imaging	$75.00 Copay after deductible	100.00%	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Imaging (CT/PET Scans, MRIs)	$175.00 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

Prescription Drugs

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Non-Preferred Brand Drugs	$70.00 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	$35.00 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	$70.00 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.

Preventive and Wellness Services and Chronic Disease Management

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Prenatal and Postnatal Care	No Charge	100.00%	Healthcare for expectant mothers before and after the birth of their child.
Well Baby Visits and Care	No Charge	100.00%	Routine doctor visits for comprehensive preventive health services that occur when a baby is young.
Preventive Care/Screening/Immunization	No Charge	100.00%	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.
Gym Membership Reimbursement	No Charge	100.00%	Partial reimbursement for facility fees every 6 months if member attains at least 50 visits.

Pediatric Vision

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.

Emergency Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Urgent Care Centers or Facilities	$75.00 Copay after deductible	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	$500.00 Copay after deductible	$500.00 Copay after deductible	Healthcare services you get in an emergency room.
Emergency Transportation/Ambulance	$300.00 Copay after deductible	$300.00 Copay after deductible	Ambulance services for an emergency medical condition.

Plan Documents

		Anthem Gatekeeper X, Bronze, ST, INN, Individual Network, Dep 25, Pediatric Dental

Price Per Month	$714.04	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	$9,450 / $9450 per person \| $18900 per group	Out-of-Network Coverage	No	Allows Health Savings Account	No
Plan Id	41046NY0010038	Persons Covered	individual	Deductible	$4,600 / $4600 per person \| $9200 per group
Specialist(s) Referral Required	Yes	Referral(s) Required	All specialists require referral with the exception of OB/GYN

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.