MVP Premier Bronze 1 HDHP, Expanded Bronze, ST, INN, NY Individual On Exchange HMO HSA, Telemedicine, Wellness DP FP Dep 29 – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: 50% after deductible
Specialist visit: 50% after deductible
Urgent care visit: 50% after deductible
SKU: 56184NY0140011
Categories: Accord, Acra, Adams, Adams Center, Addison, Adirondack, Afton, Albany, Albion, Alcove, Alden, Alder Creek, Alexander, Alexandria Bay, Alpine, Alplaus, Altamont, Altmar, Alton, Altona, Amawalk, Amenia, Amsterdam, Ancram, Ancramdale, Andes, Annandale On Hudson, Antwerp, Apalachin, Apulia Station, Arcade, Arden, Ardsley, Ardsley On Hudson, Argyle, Arkville, Armonk, Ashland, Athens, Athol, Atlanta, Attica, Au Sable Forks, Auburn, Aurora, Austerlitz, Ava, Averill Park, Avoca, Avon, Bainbridge, Bakers Mills, Baldwin Place, Baldwinsville, Ballston Lake, Ballston Spa, Barneveld, Barrytown, Barryville, Barton, Basom, Batavia, Bath, Beacon, Bear Mountain, Bearsville, Beaver Dams, Beaver Falls, Bedford, Bedford Hills, Belleville, Bellona, Bergen, Berkshire, Berlin, Berne, Bernhards Bay, Bethel, Big Flats, Big Indian, Binghamton, Black River, Blauvelt, Bliss, Blodgett Mills, Bloomfield, Blooming Grove, Bloomingburg, Bloomingdale, Bloomington, Bloomville, Blossvale, Blue Mountain Lake, Boiceville, Bolton Landing, Bombay, Boonville, Bouckville, Bovina Center, Bradford, Brainard, Brainardsville, Branchport, Brant Lake, Brantingham, Brasher Falls, Breesport, Brewerton, Brewster, Briarcliff Manor, Bridgeport, Bridgewater, Brier Hill, Broadalbin, Brockport, Bronxville, Brookfield, Brooktondale, Brownville, Brushton, Buchanan, Bullville, Burdett, Burke, Burlingham, Burlington Flats, Burnt Hills, Buskirk, Byron, Cadyville, Cairo, Calcium, Caledonia, Callicoon, Callicoon Center, Cambridge, Camden, Cameron, Cameron Mills, Camillus, Campbell, Campbell Hall, Canaan, Canajoharie, Canandaigua, Canastota, Candor, Canisteo, Canton, Cape Vincent, Carlisle, Carmel, Caroga Lake, Carthage, Cassville, Castile, Castle Creek, Castleton On Hudson, Castorland, Cato, Catskill, Cayuga, Cayuta, Cazenovia, Central Bridge, Central Square, Central Valley, Chadwicks, Chaffee, Champlain, Chappaqua, Charlotteville, Chase Mills, Chateaugay, Chatham, Chaumont, Chazy, Chelsea, Chemung, Chenango Forks, Cherry Plain, Cherry Valley, Chester, Chestertown, Chichester, Childwold, Chippewa Bay, Chittenango, Churchville, Churubusco, Cicero, Cincinnatus, Circleville, Clark Mills, Clarksville, Claryville, Claverack, Clay, Clayton, Clayville, Clemons, Cleveland, Cleverdale, Clifton Park, Clifton Springs, Climax, Clinton, Clinton Corners, Clintondale, Clyde, Cobleskill, Cochecton, Coeymans, Coeymans Hollow, Cohocton, Cohoes, Cold Brook, Cold Spring, Colliersville, Colton, Comstock, Conesus, Congers, Conklin, Connelly, Constable, Constableville, Constantia, Coopers Plains, Cooperstown, Copake, Copake Falls, Copenhagen, Corfu, Corinth, Corning, Cornwall, Cornwall On Hudson, Cornwallville, Cortland, Cortlandt Manor, Cossayuna, Cottekill, Cowlesville, Coxsackie, Cragsmoor, Cranberry Lake, Craryville, Croghan, Crompond, Cropseyville, Cross River, Croton Falls, Croton On Hudson, Crown Point, Cuddebackville, Dale, Dannemora, Dansville, Darien Center, Davenport, Davenport Center, De Kalb Junction, De Peyster, De Ruyter, Deansboro, Deferiet, Delancey, Delanson, Delhi, Delmar, Delphi Falls, Denver, Depauville, Deposit, Dexter, Diamond Point, Dickinson Center, Dobbs Ferry, Dolgeville, Dover Plains, Downsville, Dresden, Dryden, Duanesburg, Dundee, Durham, Durhamville, Eagle Bay, Eagle Bridge, Earlton, Earlville, East Berne, East Bethany, East Branch, East Chatham, East Durham, East Greenbush, East Jewett, East Meredith, East Nassau, East Pembroke, East Rochester, East Schodack, East Springfield, East Syracuse, East Worcester, Eastchester, Eaton, Edmeston, Edwards, Elba, Elbridge, Eldred, Elizabethtown, Elizaville, Elka Park, Ellenburg, Ellenburg Center, Ellenburg Depot, Ellenville, Ellisburg, Elmira, Elmsford, Endicott, Erieville, Erin, Esopus, Esperance, Essex, Etna, Evans Mills, Fabius, Fairport, Fallsburg, Farmington, Fayette, Fayetteville, Felts Mills, Ferndale, Feura Bush, Fine, Fishers, Fishers Landing, Fishkill, Fishs Eddy, Fleischmanns, Florida, Fly Creek, Fonda, Forestburgh, Forestport, Fort Ann, Fort Covington, Fort Drum, Fort Edward, Fort Hunter, Fort Johnson, Fort Montgomery, Fort Plain, Frankfort, Franklin, Freehold, Freeville, Fremont Center, Fulton, Fultonham, Fultonville, Gabriels, Gainesville, Galway, Gansevoort, Gardiner, Garnerville, Garrattsville, Garrison, Geneseo, Geneva, Genoa, Georgetown, Germantown, Ghent, Gilbertsville, Gilboa, Glasco, Glen Aubrey, Glen Spey, Glen Wild, Glenfield, Glenford, Glenham, Glenmont, Glens Falls, Gloversville, Goldens Bridge, Goshen, Gouverneur, Grafton, Grahamsville, Grand Gorge, Granite Springs, Granville, Great Bend, Greene, Greenfield Center, Greenfield Park, Greenville, Greenwich, Greenwood, Greenwood Lake, Greig, Groton, Groveland, Guilderland, Guilderland Center, Guilford, Hadley, Hagaman, Hague, Haines Falls, Halcottsville, Hall, Hamden, Hamilton, Hamlin, Hammond, Hammondsport, Hampton, Hancock, Hankins, Hannacroix, Hannawa Falls, Hannibal, Harford, Harpersfield, Harpursville, Harriman, Harris, Harrison, Harrisville, Hartford, Hartsdale, Hartwick, Hastings, Hastings On Hudson, Haverstraw, Hawthorne, Hector, Helena, Hemlock, Henderson, Henderson Harbor, Henrietta, Hensonville, Herkimer, Hermon, Heuvelton, High Falls, Highland, Highland Falls, Highland Lake, Highland Mills, Highmount, Hillburn, Hillsdale, Hilton, Himrod, Hinckley, Hobart, Hoffmeister, Hogansburg, Holland Patent, Holley, Hollowville, Holmes, Homer, Honeoye, Honeoye Falls, Hoosick Falls, Hopewell Junction, Horseheads, Hortonville, Howells, Howes Cave, Hubbardsville, Hudson, Hudson Falls, Huguenot, Huletts Landing, Hunter, Hurley, Hurleyville, Hyde Park, Ilion, Indian Lake, Inlet, Interlaken, Ionia, Irvington, Ithaca, Jacksonville, Jamesville, Jasper, Java Center, Java Village, Jay, Jefferson, Jefferson Valley, Jeffersonville, Jewett, Johnsburg, Johnson, Johnson City, Johnsonville, Johnstown, Jordan, Jordanville, Kanona, Katonah, Kattskill Bay, Kauneonga Lake, Keene, Keene Valley, Keeseville, Kendall, Kenoza Lake, Kent, Kerhonkson, Keuka Park, Kiamesha Lake, Kinderhook, King Ferry, Kingston, Kirkville, Kirkwood, Knowlesville, La Fargeville, La Fayette, Lacona, Lagrangeville, Lake Clear, Lake George, Lake Hill, Lake Huntington, Lake Katrine, Lake Luzerne, Lake Peekskill, Lake Placid, Lake Pleasant, Lakeville, Lanesville, Lansing, Larchmont, Latham, Laurens, Le Roy, Lee Center, Leeds, Leicester, Leonardsville, Lewis, Lexington, Liberty, Lima, Lincolndale, Lindley, Linwood, Lisbon, Lisle, Little Falls, Little York, Liverpool, Livingston Manor, Livonia, Loch Sheldrake, Locke, Lockwood, Lodi, Long Eddy, Long Lake, Lorraine, Lowman, Lowville, Lyndonville, Lyon Mountain, Lyons, Lyons Falls, Macedon, Madison, Madrid, Mahopac, Mahopac Falls, Maine, Malden Bridge, Malden On Hudson, Mallory, Malone, Mamaroneck, Manchester, Manlius, Mannsville, Maplecrest, Marathon, Marcellus, Marcy, Margaretville, Marietta, Marion, Marlboro, Martinsburg, Martville, Maryknoll, Maryland, Masonville, Massena, Maybrook, Mayfield, McDonough, McGraw, McLean, Mechanicville, Medina, Medusa, Mellenville, Melrose, Memphis, Mendon, Meridale, Meridian, Mexico, Middle Granville, Middle Grove, Middleburgh, Middleport, Middlesex, Middletown, Middleville, Milford, Millbrook, Millerton, Millport, Millwood, Milton, Minerva, Minetto, Mineville, Minoa, Modena, Mohawk, Mohegan Lake, Moira, Mongaup Valley, Monroe, Monsey, Montezuma, Montgomery, Monticello, Montour Falls, Montrose, Mooers, Mooers Forks, Moravia, Moriah, Moriah Center, Morris, Morrisonville, Morristown, Morrisville, Mottville, Mount Kisco, Mount Marion, Mount Morris, Mount Tremper, Mount Upton, Mount Vernon, Mount Vision, Mountain Dale, Mountainville, Mumford, Munnsville, Nanuet, Napanoch, Naples, Narrowsburg, Nassau, Natural Bridge, Nedrow, Nelliston, Neversink, New Baltimore, New Berlin, New City, New Hampton, New Hartford, New Haven, New Kingston, New Lebanon, New Lisbon, New Paltz, New Rochelle, New Russia, New Windsor, New Woodstock, New York, New York Mills, Newark, Newark Valley, Newburgh, Newcomb, Newfield, Newport, Newton Falls, Nichols, Nicholville, Nineveh, Niverville, Norfolk, North Bangor, North Bay, North Blenheim, North Branch, North Brookfield, North Chatham, North Chili, North Creek, North Granville, North Greece, North Hudson, North Java, North Lawrence, North Norwich, North Pitcher, North River, North Rose, North Salem, Northville, Norwich, Norwood, Nunda, Nyack, Oak Hill, Oakfield, Obernburg, Odessa, Ogdensburg, Old Chatham, Old Forge, Olivebridge, Olmstedville, Oneida, Oneonta, Ontario, Orangeburg, Oriskany, Oriskany Falls, Ossining, Oswegatchie, Oswego, Otego, Otisville, Ouaquaga, Ovid, Owego, Owls Head, Oxford, Painted Post, Palatine Bridge, Palenville, Palisades, Palmyra, Paradox, Parish, Parishville, Parksville, Patterson, Pattersonville, Paul Smiths, Pavilion, Pawling, Pearl River, Peekskill, Pelham, Penfield, Penn Yan, Pennellville, Perkinsville, Perry, Peru, Peterboro, Petersburg, Phelps, Philadelphia, Phillipsport, Philmont, Phoenicia, Phoenix, Piercefield, Piermont, Pierrepont Manor, Piffard, Pike, Pine Bush, Pine City, Pine Hill, Pine Island, Pine Plains, Pine Valley, Piseco, Pitcher, Pittsford, Plattsburgh, Pleasant Valley, Pleasantville, Plessis, Plymouth, Poestenkill, Poland, Pomona, Pompey, Pond Eddy, Port Byron, Port Chester, Port Crane, Port Ewen, Port Gibson, Port Henry, Port Jervis, Port Kent, Port Leyden, Portageville, Porter Corners, Portlandville, Potsdam, Pottersville, Poughkeepsie, Poughquag, Pound Ridge, Prattsburgh, Prattsville, Preble, Preston Hollow, Prospect, Pulaski, Pulteney, Purchase, Purdys, Purling, Putnam Station, Putnam Valley, Queensbury, Rainbow Lake, Raquette Lake, Ravena, Ray Brook, Raymondville, Red Creek, Red Hook, Redfield, Redford, Redwood, Remsen, Rensselaer, Rensselaer Falls, Rensselaerville, Retsof, Rexford, Rhinebeck, Rhinecliff, Richfield Springs, Richford, Richland, Richmondville, Richville, Rifton, Riparius, Rochester, Rock City Falls, Rock Hill, Rock Stream, Rock Tavern, Rodman, Rome, Romulus, Roscoe, Rose, Roseboom, Rosendale, Rotterdam Junction, Round Lake, Round Top, Rouses Point, Roxbury, Ruby, Rush, Rushville, Russell, Rye, Sabael, Sackets Harbor, Saint Johnsville, Saint Regis Falls, Salem, Salisbury Center, Salisbury Mills, Salt Point, Sand Lake, Sandy Creek, Sangerfield, Saranac, Saranac Lake, Saratoga Springs, Saugerties, Sauquoit, Savannah, Savona, Scarsdale, Schaghticoke, Schenectady, Schenevus, Schodack Landing, Schoharie, Schroon Lake, Schuyler Falls, Schuyler Lake, Schuylerville, Scipio Center, Scottsburg, Scottsville, Selkirk, Seneca Falls, Severance, Shandaken, Sharon Springs, Sherburne, Sherrill, Shokan, Shortsville, Shrub Oak, Shushan, Sidney, Sidney Center, Silver Bay, Silver Lake, Silver Springs, Skaneateles, Skaneateles Falls, Slate Hill, Slaterville Springs, Slingerlands, Sloansville, Sloatsburg, Smallwood, Smithville Flats, Smyrna, Sodus, Sodus Point, Somers, Sonyea, South Bethlehem, South Butler, South Byron, South Cairo, South Colton, South Fallsburg, South Glens Falls, South Kortright, South New Berlin, South Otselic, South Plymouth, South Salem, Southfields, Sparkill, Sparrow Bush, Speculator, Spencer, Spencerport, Spencertown, Sprakers, Spring Glen, Spring Valley, Springfield Center, Springwater, Staatsburg, Stafford, Stamford, Stanfordville, Stanley, Star Lake, Stephentown, Sterling, Sterling Forest, Stillwater, Stittville, Stone Ridge, Stony Creek, Stony Point, Stormville, Stottville, Stratford, Strykersville, Stuyvesant, Stuyvesant Falls, Suffern, Summit, Summitville, Surprise, Swan Lake, Sylvan Beach, Syracuse, Taberg, Tannersville, Tappan, Tarrytown, Thendara, Theresa, Thiells, Thompson Ridge, Thompsonville, Thornwood, Thousand Island Park, Three Mile Bay, Ticonderoga, Tillson, Tivoli, Tomkins Cove, Treadwell, Tribes Hill, Troupsburg, Trout Creek, Troy, Trumansburg, Truxton, Tuckahoe, Tully, Tupper Lake, Turin, Tuxedo Park, Ulster Park, Unadilla, Union Springs, Unionville, Upper Jay, Utica, Valatie, Valhalla, Valley Cottage, Valley Falls, Van Etten, Van Hornesville, Varysburg, Verbank, Vermontville, Vernon, Vernon Center, Verona, Verona Beach, Verplanck, Vestal, Victor, Victory Mills, Voorheesville, Waccabuc, Waddington, Walden, Wallkill, Walton, Walworth, Wampsville, Wanakena, Wappingers Falls, Warners, Warnerville, Warrensburg, Warsaw, Warwick, Washingtonville, Wassaic, Waterford, Waterloo, Waterport, Watertown, Waterville, Watervliet, Watkins Glen, Waverly, Wawarsing, Wayland, Wayne, Webster, Weedsport, Wellesley Island, Wells, Wells Bridge, Wellsburg, West Bloomfield, West Burlington, West Camp, West Chazy, West Coxsackie, West Davenport, West Eaton, West Edmeston, West Fulton, West Harrison, West Haverstraw, West Henrietta, West Hurley, West Kill, West Lebanon, West Leyden, West Monroe, West Nyack, West Oneonta, West Park, West Point, West Sand Lake, West Shokan, West Stockholm, West Winfield, Westbrookville, Westdale, Westerlo, Westernville, Westford, Westmoreland, Westport, Westtown, Wevertown, White Lake, White Plains, White Sulphur Springs, Whitehall, Whitesboro, Whitney Point, Willard, Willet, Williamson, Williamstown, Willow, Willsboro, Willseyville, Wilmington, Windham, Windsor, Wingdale, Winthrop, Witherbee, Wolcott, Woodbourne, Woodgate, Woodhull, Woodridge, Woodstock, Worcester, Wurtsboro, Wynantskill, Wyoming, Yonkers, York, Yorktown Heights, Yorkville, Youngsville, Yulan
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $6,100 per person $6,100 per person |
| Out-of-pocket max | $7,150 per person $14,300 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | 50% after deductible |
| Specialist visit | 50% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 50% after deductible |
| Emergency room | 50% after deductible |
| Ambulance | 50% after deductible |
| Hospital stay (facility) | 50% after deductible |
| Hospital stay (physician) | 50% after deductible |
| Outpatient procedure (facility) | 50% after deductible |
| Outpatient procedure (physician) | 50% after deductible |
| Physical rehabilitation | 50% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 50% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay after deductible |
| Brand | $35 copay after deductible |
| Non-preferred Brand | $70 copay after deductible |
| Specialty | $70 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 50% after deductible |
| Imaging (CT/PET/MRI) | 50% after deductible |
| Blood work | 50% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 50% after deductible |
| Psychiatric hospital stay | 50% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/vQn7wQbqqDsJnrzBBr9nCH4B.pdf |
