HMO Copayment 14, Platinum, NS, INN, , Adult Vision, Lasik, Wellness DP FP – HMO
Network type: HMO
Coverage tier: Platinum
Primary care visit: No charge
Specialist visit: $25 copay
Urgent care visit: $50 copay
SKU: 94788NY0280147
Categories: Accord, Acra, Adams, Adams Center, Adirondack, Afton, Albany, Alcove, Alder Creek, Alexandria Bay, Alplaus, Altamont, Altona, Amenia, Amsterdam, Ancram, Ancramdale, Andes, Annandale On Hudson, Antwerp, Apalachin, Arden, Argyle, Arkville, Ashland, Athens, Athol, Au Sable Forks, Austerlitz, Ava, Averill Park, Bainbridge, Bakers Mills, Ballston Lake, Ballston Spa, Barneveld, Barrytown, Barton, Beacon, Bearsville, Beaver Falls, Belleville, Berlin, Berne, Big Indian, Binghamton, Black River, Blooming Grove, Bloomingdale, Bloomington, Bloomville, Blossvale, Blue Mountain Lake, Boiceville, Bolton Landing, Bombay, Boonville, Bouckville, Bovina Center, Brainard, Brainardsville, Brant Lake, Brantingham, Brasher Falls, Bridgewater, Brier Hill, Broadalbin, Brookfield, Brownville, Brushton, Bullville, Burke, Burlington Flats, Burnt Hills, Buskirk, Cadyville, Cairo, Calcium, Cambridge, Camden, Campbell Hall, Canaan, Canajoharie, Canastota, Candor, Canton, Cape Vincent, Carlisle, Caroga Lake, Carthage, Cassville, Castle Creek, Castleton On Hudson, Castorland, Catskill, Central Bridge, Central Valley, Chadwicks, Champlain, Charlotteville, Chase Mills, Chateaugay, Chatham, Chaumont, Chazy, Chelsea, Chenango Forks, Cherry Plain, Cherry Valley, Chester, Chestertown, Chichester, Childwold, Chippewa Bay, Churubusco, Circleville, Clark Mills, Clarksville, Claryville, Claverack, Clayton, Clayville, Clemons, Cleverdale, Clifton Park, Climax, Clinton, Clinton Corners, Clintondale, Cobleskill, Coeymans, Coeymans Hollow, Cohoes, Cold Brook, Colliersville, Colton, Comstock, Conklin, Connelly, Constable, Constableville, Cooperstown, Copake, Copake Falls, Copenhagen, Corinth, Cornwall, Cornwall On Hudson, Cornwallville, Cossayuna, Cottekill, Coxsackie, Cragsmoor, Cranberry Lake, Craryville, Croghan, Cropseyville, Crown Point, Dannemora, Davenport, Davenport Center, De Kalb Junction, De Peyster, Deansboro, Deferiet, Delancey, Delanson, Delhi, Delmar, Denver, Depauville, Deposit, Dexter, Diamond Point, Dickinson Center, Dolgeville, Dover Plains, Downsville, Duanesburg, Durham, Durhamville, Eagle Bay, Eagle Bridge, Earlton, Earlville, East Berne, East Branch, East Chatham, East Durham, East Greenbush, East Jewett, East Meredith, East Nassau, East Schodack, East Springfield, East Worcester, Eaton, Edmeston, Edwards, Elizabethtown, Elizaville, Elka Park, Ellenburg, Ellenburg Center, Ellenburg Depot, Ellenville, Ellisburg, Endicott, Erieville, Esopus, Esperance, Essex, Evans Mills, Felts Mills, Feura Bush, Fine, Fishers Landing, Fishkill, Fishs Eddy, Fleischmanns, Florida, Fly Creek, Fonda, Forestport, Fort Ann, Fort Covington, Fort Drum, Fort Edward, Fort Hunter, Fort Johnson, Fort Montgomery, Fort Plain, Frankfort, Franklin, Freehold, Fultonham, Fultonville, Gabriels, Galway, Gansevoort, Gardiner, Garrattsville, Georgetown, Germantown, Ghent, Gilbertsville, Gilboa, Glasco, Glen Aubrey, Glenfield, Glenford, Glenham, Glenmont, Glens Falls, Gloversville, Goshen, Gouverneur, Grafton, Grahamsville, Grand Gorge, Granville, Great Bend, Greene, Greenfield Center, Greenfield Park, Greenville, Greenwich, Greenwood Lake, Greig, Guilderland, Guilderland Center, Guilford, Hadley, Hagaman, Hague, Haines Falls, Halcottsville, Hamden, Hamilton, Hammond, Hampton, Hancock, Hannacroix, Hannawa Falls, Harpersfield, Harpursville, Harriman, Harrisville, Hartford, Hartwick, Helena, Henderson, Henderson Harbor, Hensonville, Herkimer, Hermon, Heuvelton, High Falls, Highland, Highland Falls, Highland Mills, Highmount, Hillsdale, Hinckley, Hobart, Hoffmeister, Hogansburg, Holland Patent, Hollowville, Hoosick Falls, Howells, Howes Cave, Hubbardsville, Hudson, Hudson Falls, Huguenot, Huletts Landing, Hunter, Hurley, Hyde Park, Ilion, Indian Lake, Inlet, Jay, Jefferson, Jewett, Johnsburg, Johnson, Johnson City, Johnsonville, Johnstown, Jordanville, Kattskill Bay, Keene, Keene Valley, Keeseville, Kerhonkson, Kinderhook, Kingston, Kirkwood, La Fargeville, Lagrangeville, Lake Clear, Lake George, Lake Hill, Lake Katrine, Lake Luzerne, Lake Placid, Lake Pleasant, Lanesville, Latham, Laurens, Lee Center, Leeds, Leonardsville, Lewis, Lexington, Lisbon, Lisle, Little Falls, Livingston Manor, Lockwood, Long Lake, Lorraine, Lowville, Lyon Mountain, Lyons Falls, Madison, Madrid, Maine, Malden Bridge, Malden On Hudson, Malone, Mannsville, Maplecrest, Marcy, Margaretville, Marlboro, Martinsburg, Maryland, Masonville, Massena, Maybrook, Mayfield, McDonough, Mechanicville, Medusa, Mellenville, Melrose, Meridale, Middle Granville, Middle Grove, Middleburgh, Middletown, Middleville, Milford, Millbrook, Millerton, Milton, Minerva, Mineville, Modena, Mohawk, Moira, Monroe, Montgomery, Mooers, Mooers Forks, Moriah, Moriah Center, Morris, Morrisonville, Morristown, Morrisville, Mount Marion, Mount Tremper, Mount Upton, Mount Vision, Mountainville, Munnsville, Napanoch, Nassau, Natural Bridge, Nelliston, New Baltimore, New Berlin, New Hampton, New Hartford, New Kingston, New Lebanon, New Lisbon, New Paltz, New Russia, New Windsor, New York, New York Mills, Newark Valley, Newburgh, Newcomb, Newport, Newton Falls, Nichols, Nicholville, Nineveh, Niverville, Norfolk, North Bangor, North Bay, North Blenheim, North Brookfield, North Chatham, North Creek, North Granville, North Hudson, North Lawrence, North Norwich, North Pitcher, North River, Northville, Norwich, Norwood, Oak Hill, Ogdensburg, Old Chatham, Old Forge, Olivebridge, Olmstedville, Oneida, Oneonta, Oriskany, Oriskany Falls, Oswegatchie, Otego, Otisville, Ouaquaga, Owego, Owls Head, Oxford, Palatine Bridge, Palenville, Paradox, Parishville, Pattersonville, Paul Smiths, Pawling, Peru, Peterboro, Petersburg, Philadelphia, Philmont, Phoenicia, Piercefield, Pierrepont Manor, Pine Bush, Pine Hill, Pine Island, Pine Plains, Piseco, Pitcher, Plattsburgh, Pleasant Valley, Plessis, Plymouth, Poestenkill, Poland, Port Crane, Port Ewen, Port Henry, Port Jervis, Port Kent, Port Leyden, Porter Corners, Portlandville, Potsdam, Pottersville, Poughkeepsie, Poughquag, Prattsville, Preston Hollow, Prospect, Purling, Putnam Station, Queensbury, Rainbow Lake, Raquette Lake, Ravena, Ray Brook, Raymondville, Red Hook, Redford, Redwood, Remsen, Rensselaer, Rensselaer Falls, Rensselaerville, Rexford, Rhinebeck, Rhinecliff, Richfield Springs, Richford, Richmondville, Richville, Rifton, Riparius, Rock City Falls, Rock Tavern, Rodman, Rome, Roseboom, Rosendale, Rotterdam Junction, Round Lake, Round Top, Rouses Point, Roxbury, Ruby, Russell, Sabael, Sackets Harbor, Saint Johnsville, Saint Regis Falls, Salem, Salisbury Center, Salisbury Mills, Salt Point, Sand Lake, Sangerfield, Saranac, Saranac Lake, Saratoga Springs, Saugerties, Sauquoit, Schaghticoke, Schenectady, Schenevus, Schodack Landing, Schoharie, Schroon Lake, Schuyler Falls, Schuyler Lake, Schuylerville, Selkirk, Severance, Shandaken, Sharon Springs, Sherburne, Sherrill, Shokan, Shushan, Sidney, Sidney Center, Silver Bay, Slate Hill, Slingerlands, Sloansville, Smyrna, South Bethlehem, South Cairo, South Colton, South Glens Falls, South Kortright, South New Berlin, South Otselic, South Plymouth, Southfields, Speculator, Spencertown, Sprakers, Spring Glen, Springfield Center, Staatsburg, Stamford, Stanfordville, Star Lake, Stephentown, Sterling Forest, Stillwater, Stittville, Stone Ridge, Stony Creek, Stottville, Stratford, Stuyvesant, Stuyvesant Falls, Summit, Surprise, Sylvan Beach, Taberg, Tannersville, Thendara, Theresa, Thompson Ridge, Thousand Island Park, Three Mile Bay, Ticonderoga, Tillson, Tivoli, Treadwell, Tribes Hill, Trout Creek, Troy, Tupper Lake, Turin, Tuxedo Park, Ulster Park, Unadilla, Unionville, Upper Jay, Utica, Valatie, Valley Falls, Van Etten, Van Hornesville, Verbank, Vermontville, Vernon, Vernon Center, Verona, Verona Beach, Vestal, Victory Mills, Voorheesville, Waddington, Walden, Wallkill, Walton, Wampsville, Wanakena, Wappingers Falls, Warnerville, Warrensburg, Warwick, Washingtonville, Wassaic, Waterford, Watertown, Waterville, Watervliet, Waverly, Wawarsing, Wellesley Island, Wells, Wells Bridge, West Burlington, West Camp, West Chazy, West Coxsackie, West Davenport, West Eaton, West Edmeston, West Fulton, West Hurley, West Kill, West Lebanon, West Leyden, West Oneonta, West Park, West Point, West Sand Lake, West Shokan, West Stockholm, West Winfield, Westdale, Westerlo, Westernville, Westford, Westmoreland, Westport, Westtown, Wevertown, Whitehall, Whitesboro, Willow, Willsboro, Wilmington, Windham, Windsor, Wingdale, Winthrop, Witherbee, Woodgate, Woodstock, Worcester, Wynantskill, Yorkville
Description
Health Care Plan Details
Network type | HMO |
Deductible | $0 per person $0 per person |
Out-of-pocket max | $3,000 per person $6,000 per family |
Metal tier | Platinum |
Visit Copay
Primary care visit | No charge |
Specialist visit | $25 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $50 copay |
Emergency room | $200 copay |
Ambulance | $200 copay |
Hospital stay (facility) | $250 copay |
Hospital stay (physician) | No charge |
Outpatient procedure (facility) | $100 copay |
Outpatient procedure (physician) | $100 copay |
Physical rehabilitation | $25 copay |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | $250 copay |
Pharmacy, Drugs, and Medication
Generic | $5 copay |
Brand | $15 copay |
Non-preferred Brand | $45 copay |
Lab Tests and Diagnostic Procedures
X-rays | $25 copay |
Imaging (CT/PET/MRI) | $25 copay |
Blood work | $25 copay |
Mental and Psychiatric Health Care
Mental Health outpatient services | No charge |
Psychiatric hospital stay | $250 copay |