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		Select Care Bronze, Bronze, ST, INN, Dep25

Price Per Month	$424.57	Metal	Bronze	Overall Quality Rating	Quality Details
Maximum Out of Pocket	$6,350 / $12,700	Out-of-Network Coverage	No	Allows Health Savings Account	No
Plan Id	88582NY0170001	Persons Covered	individual	Deductible	$3,000 / $6,000
Specialist(s) Referral Required Yes		Referral(s) Required

Design	All Plans require a written Referral from your PCP before receiving Specialist care. Select Care is a tailored network, which features high-quality, community-based primary care and specialty providers who offer you a personal, caring experience. The Select Care network includes doctors in private practice, physician group practices and Advantage Care Physicians. You can find doctors throughout 28 New York counties-including New York City and its surrounding counties, with access extending to regions north of Albany. The plans include Telehealth, with physician consultations and dietician services. The Telehealth benefit is not subject to the deductible for any of the metal plans.

Design

All Plans require a written Referral from your PCP before receiving Specialist care. Select Care is a tailored network, which features high-quality, community-based primary care and specialty providers who offer you a personal, caring experience. The Select Care network includes doctors in private practice, physician group practices and Advantage Care Physicians. You can find doctors throughout 28 New York counties-including New York City and its surrounding counties, with access extending to regions north of Albany. The plans include Telehealth, with physician consultations and dietician services. The Telehealth benefit is not subject to the deductible for any of the metal plans.

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
Mental/Behavioral Health Inpatient Services	50%	$0	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	50%	$0	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.
Substance Abuse Disorder Inpatient Services	50%	$0	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%	$0	Diagnosis and treatment of alcoholism and/or substance use and/or dependency in an outpatient setting.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Non-Preferred Brand Drugs	$70	$0	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	$0	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	$10	$0	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
Other Practitioner Office Visit (Nurse, Physician Assistant)	50%	$0
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	50%	$0
Outpatient Surgery Physician/Surgical Services	50%	$0	Surgical services performed by a physician or surgeon in an outpatient facility.
Primary Care Visit to Treat an Injury or Illness	50%	$0	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.
Specialist Visit	50%	$0	Visits to a physician to diagnose, manage, prevent or treat certain types of symptoms and conditions related to a specific disease or condition.
Home Health Care Services	50%	$0	Health care services a person receives at home.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Post-Mastectomy Care	50%	$0
Transplant	50%	$0	Transplants determined to be non-experimental and non-investigational are covered, including but 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.
Autism Spectrum Disorders	50%	$0	Coverage applicable to ABA treatment for autism spectrum disorders.
Chemotherapy	50%	$0	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.
Diabetes Care Management	50%	$0
Diabetic Equipment & Supplies	50%	$0	Diabetic equipment, supplies, and self-management education if recommended or prescribed by a physician or other licensed health care professional.
Family Planning Services	$0	$0	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
Prenatal and Postnatal Care	$0	$0	Healthcare for expectant mothers before and after the birth of their child.
Preventive Care/Screening/Immunization	$0	$0	Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Well Baby Visits and Care	$0	$0	Routine doctor visits for comprehensive preventive health services that occur when a baby is young.
Gym Membership Reimbursement	No Charge	$0	Partial reimbursement for facility fees every 6 months if member attains at least 50 visits.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Routine Eye Exam for Children	50%	$0	Emergency, preventive and routine vision care for children.
Contact Lenses for Children	50%	$0	Standard prescription contact lenses once in any twelve (12) month period.
Eye Glasses for Children	50%	$0	Standard prescription lenses once in any twelve (12) month period. Prescription lenses may be constructed of either glass or plastic. Standard frames adequate to hold lenses once in any twelve (12) month period are also covered.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Skilled Nursing Facility	$0 Copay per Stay	$0 Copay per Stay	A facility that performs skilled nursing care and rehabilitation services provided on a continuous, daily basis.
Delivery and All Inpatient Services for Maternity Care	50%	$0	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)	$0 Copay per Stay	$0 Copay per Stay	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	50%	$0	Surgical services performed by a physician or surgeon in an inpatient facility.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Urgent Care Centers or Facilities	50%	$0	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	50%	$0	Healthcare services you get in an emergency room.
Emergency Transportation/Ambulance	50%	$0	Ambulance services for an emergency medical condition.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
X-rays and Diagnostic Imaging	50%	$0	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Imaging (CT/PET Scans, MRIs)	50%	$0	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition
Laboratory Outpatient and Professional Services	50%	$0	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible	Description
Prosthetic Devices	50%	$0	1 external prosthetic device per limb per lifetime (limit does not apply to internal devices)
Outpatient Rehabilitation Services	50%	$0	60 visits per condition per lifetime combined. Speech & physical therapy are only covered following a hospital stay or surgery.
Inpatient Rehabilitation Services	50%	$0	60 consecutive days per condition per lifetime.
Chiropractic Care	50%	$0	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	50%	$0	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.

		Select Care Bronze, Bronze, ST, INN, Dep25

Price Per Month	$424.57	Metal	Bronze	Overall Quality Rating
Maximum Out of Pocket	$6,350 / $12,700	Out-of-Network Coverage	No	Allows Health Savings Account	No
Plan Id	88582NY0170001	Persons Covered	individual	Deductible	$3,000 / $6,000
Specialist(s) Referral Required	Yes	Referral(s) Required

Design	All Plans require a written Referral from your PCP before receiving Specialist care. Select Care is a tailored network, which features high-quality, community-based primary care and specialty providers who offer you a personal, caring experience. The Select Care network includes doctors in private practice, physician group practices and Advantage Care Physicians. You can find doctors throughout 28 New York counties-including New York City and its surrounding counties, with access extending to regions north of Albany. The plans include Telehealth, with physician consultations and dietician services. The Telehealth benefit is not subject to the deductible for any of the metal plans.

Design

Mental Health and Substance Abuse Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Mental/Behavioral Health Inpatient Services	50%	$0	Diagnosis and treatment of mental, nervous and emotional disorders performed in an inpatient setting.
Mental/Behavioral Health Outpatient Services	50%	$0	Diagnosis and treatment of mental, nervous and emotional disorders performed in an outpatient setting.
Substance Abuse Disorder Inpatient Services	50%	$0	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%	$0	Diagnosis and treatment of alcoholism and/or substance use and/or dependency in an outpatient setting.

Prescription Drugs

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Non-Preferred Brand Drugs	$70	$0	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	$0	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	$10	$0	A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.

Outpatient Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)	50%	$0
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	50%	$0
Outpatient Surgery Physician/Surgical Services	50%	$0	Surgical services performed by a physician or surgeon in an outpatient facility.
Primary Care Visit to Treat an Injury or Illness	50%	$0	Visit to a clinician for health services that cover a range of prevention, wellness, and treatment for common illnesses.
Specialist Visit	50%	$0	Visits to a physician to diagnose, manage, prevent or treat certain types of symptoms and conditions related to a specific disease or condition.
Home Health Care Services	50%	$0	Health care services a person receives at home.

Other Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Post-Mastectomy Care	50%	$0
Transplant	50%	$0	Transplants determined to be non-experimental and non-investigational are covered, including but 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.
Autism Spectrum Disorders	50%	$0	Coverage applicable to ABA treatment for autism spectrum disorders.
Chemotherapy	50%	$0	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.
Diabetes Care Management	50%	$0
Diabetic Equipment & Supplies	50%	$0	Diabetic equipment, supplies, and self-management education if recommended or prescribed by a physician or other licensed health care professional.
Family Planning Services	$0	$0	Counseling on the use of contraceptives, sterilization procedures, and related topics.

Preventive and Wellness Services and Chronic Disease Management

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Prenatal and Postnatal Care	$0	$0	Healthcare for expectant mothers before and after the birth of their child.
Preventive Care/Screening/Immunization	$0	$0	Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.
Well Baby Visits and Care	$0	$0	Routine doctor visits for comprehensive preventive health services that occur when a baby is young.
Gym Membership Reimbursement	No Charge	$0	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
Routine Eye Exam for Children	50%	$0	Emergency, preventive and routine vision care for children.
Contact Lenses for Children	50%	$0	Standard prescription contact lenses once in any twelve (12) month period.
Eye Glasses for Children	50%	$0	Standard prescription lenses once in any twelve (12) month period. Prescription lenses may be constructed of either glass or plastic. Standard frames adequate to hold lenses once in any twelve (12) month period are also covered.

Hospitalization

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Skilled Nursing Facility	$0 Copay per Stay	$0 Copay per Stay	A facility that performs skilled nursing care and rehabilitation services provided on a continuous, daily basis.
Delivery and All Inpatient Services for Maternity Care	50%	$0	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)	$0 Copay per Stay	$0 Copay per Stay	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	50%	$0	Surgical services performed by a physician or surgeon in an inpatient facility.

Emergency Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Urgent Care Centers or Facilities	50%	$0	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	50%	$0	Healthcare services you get in an emergency room.
Emergency Transportation/Ambulance	50%	$0	Ambulance services for an emergency medical condition.

Laboratory Outpatient and Professional Services

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
X-rays and Diagnostic Imaging	50%	$0	X-rays and other technologies that doctors use in the diagnosis of a medical condition
Imaging (CT/PET Scans, MRIs)	50%	$0	Imaging technologies such as CT and PET Scans and MRIs that doctors use in the treatment of a medical condition
Laboratory Outpatient and Professional Services	50%	$0	Professional fees and services associated with laboratory work for diagnostic and treatment purposes.

Rehabilitative and Habilitative Services and Devices

Benefit	In Network Cost Share	Out of Network Cost Share	Subject to Deductible
Prosthetic Devices	50%	$0	1 external prosthetic device per limb per lifetime (limit does not apply to internal devices)
Outpatient Rehabilitation Services	50%	$0	60 visits per condition per lifetime combined. Speech & physical therapy are only covered following a hospital stay or surgery.
Inpatient Rehabilitation Services	50%	$0	60 consecutive days per condition per lifetime.
Chiropractic Care	50%	$0	Care performed by a Doctor of Chiropractic (Chiropractor).
Durable Medical Equipment	50%	$0	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.

Plan Documents

Customer Service	www.emblemhealth.com
Summary of Benefits and Coverage	http://emblemhealth.com/exchange
Prescription Drug List	http://www.emblemhealth.com/Pharmacy/See-Covered-Drugs.aspx
Provider Network	http://portals.emblemhealth.com/ProviderSearchEHHIP/Default.aspx?Plan=SCSI&Network=SELC
Plan Brochure	http://emblemhealth.com/exchange
Payment Information	www.emblemhealth.com/firstpayment

Plan Details