MVP Premier Platinum 1, Platinum, ST, INN, NY Individual On Exchange HMO Telemedicine, Wellness DP FP Dep 29 – HMO

Network type: HMO
Coverage tier: Platinum
Primary care visit: $15 copay
Specialist visit: $35 copay
Urgent care visit: $55 copay

SKU: 56184NY0140017 Categories: Accord, Acra, Adams, Adams Center, Adirondack, Afton, Albany, Alcove, Alder Creek, Alexandria Bay, Alplaus, Altamont, Altona, Amawalk, Amenia, Amsterdam, Ancram, Ancramdale, Andes, Annandale On Hudson, Antwerp, Arden, Ardsley, Ardsley On Hudson, Argyle, Arkville, Armonk, Ashland, Athens, Athol, Au Sable Forks, Austerlitz, Ava, Averill Park, Bainbridge, Bakers Mills, Baldwin Place, Ballston Lake, Ballston Spa, Barneveld, Barrytown, Barryville, Beacon, Bearsville, Beaver Falls, Bedford, Bedford Hills, Belleville, Berlin, Berne, Bethel, Big Indian, Binghamton, Black River, Blooming Grove, Bloomingburg, Bloomingdale, Bloomington, Bloomville, Blossvale, Blue Mountain Lake, Boiceville, Bolton Landing, Bombay, Boonville, Bouckville, Bovina Center, Brainard, Brainardsville, Brant Lake, Brantingham, Brasher Falls, Brewster, Briarcliff Manor, Bridgewater, Brier Hill, Broadalbin, Bronxville, Brookfield, Brownville, Brushton, Buchanan, Bullville, Burke, Burlingham, Burlington Flats, Burnt Hills, Buskirk, Cadyville, Cairo, Calcium, Callicoon, Callicoon Center, Cambridge, Camden, Campbell Hall, Canaan, Canajoharie, Canastota, Canton, Cape Vincent, Carlisle, Carmel, Caroga Lake, Carthage, Cassville, Castle Creek, Castleton On Hudson, Castorland, Catskill, Central Bridge, Central Valley, Chadwicks, Champlain, Chappaqua, 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, Cochecton, Coeymans, Coeymans Hollow, Cohoes, Cold Brook, Cold Spring, Colliersville, Colton, Comstock, Conklin, Connelly, Constable, Constableville, Cooperstown, Copake, Copake Falls, Copenhagen, Corinth, Cornwall, Cornwall On Hudson, Cornwallville, Cortlandt Manor, Cossayuna, Cottekill, Coxsackie, Cragsmoor, Cranberry Lake, Craryville, Croghan, Crompond, Cropseyville, Cross River, Croton Falls, Croton On Hudson, Crown Point, Cuddebackville, Dannemora, Davenport, Davenport Center, De Kalb Junction, De Peyster, Deansboro, Deferiet, Delancey, Delanson, Delhi, Delmar, Denver, Depauville, Deposit, Dexter, Diamond Point, Dickinson Center, Dobbs Ferry, 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, Eastchester, Eaton, Edmeston, Edwards, Eldred, Elizabethtown, Elizaville, Elka Park, Ellenburg, Ellenburg Center, Ellenburg Depot, Ellenville, Ellisburg, Elmsford, Erieville, Esopus, Esperance, Essex, Evans Mills, Fallsburg, Felts Mills, Ferndale, Feura Bush, Fine, 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, Fremont Center, Fultonham, Fultonville, Gabriels, Galway, Gansevoort, Gardiner, Garrattsville, Garrison, 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 Lake, Greig, Guilderland, Guilderland Center, Guilford, Hadley, Hagaman, Hague, Haines Falls, Halcottsville, Hamden, Hamilton, Hammond, Hampton, Hancock, Hankins, Hannacroix, Hannawa Falls, Harpersfield, Harpursville, Harriman, Harris, Harrison, Harrisville, Hartford, Hartsdale, Hartwick, Hastings On Hudson, Hawthorne, Helena, Henderson, Henderson Harbor, Hensonville, Herkimer, Hermon, Heuvelton, High Falls, Highland, Highland Falls, Highland Lake, Highland Mills, Highmount, Hillsdale, Hinckley, Hobart, Hoffmeister, Hogansburg, Holland Patent, Hollowville, Holmes, Hoosick Falls, Hopewell Junction, Hortonville, Howells, Howes Cave, Hubbardsville, Hudson, Hudson Falls, Huguenot, Huletts Landing, Hunter, Hurley, Hurleyville, Hyde Park, Ilion, Indian Lake, Inlet, Irvington, Jay, Jefferson, Jefferson Valley, Jeffersonville, Jewett, Johnsburg, Johnson, Johnson City, Johnsonville, Johnstown, Jordanville, Katonah, Kattskill Bay, Kauneonga Lake, Keene, Keene Valley, Keeseville, Kenoza Lake, Kerhonkson, Kiamesha Lake, Kinderhook, Kingston, Kirkwood, La Fargeville, Lagrangeville, Lake Clear, Lake George, Lake Hill, Lake Huntington, Lake Katrine, Lake Luzerne, Lake Peekskill, Lake Placid, Lake Pleasant, Lanesville, Larchmont, Latham, Laurens, Lee Center, Leeds, Leonardsville, Lewis, Lexington, Liberty, Lincolndale, Lisbon, Lisle, Little Falls, Livingston Manor, Loch Sheldrake, Long Eddy, Long Lake, Lorraine, Lowville, Lyon Mountain, Lyons Falls, Madison, Madrid, Mahopac, Mahopac Falls, Maine, Malden Bridge, Malden On Hudson, Malone, Mamaroneck, Mannsville, Maplecrest, Marcy, Margaretville, Marlboro, Martinsburg, Maryknoll, Maryland, Masonville, Massena, Maybrook, Mayfield, McDonough, Mechanicville, Medusa, Mellenville, Melrose, Meridale, Middle Granville, Middle Grove, Middleburgh, Middletown, Middleville, Milford, Millbrook, Millerton, Millwood, Milton, Minerva, Mineville, Modena, Mohawk, Mohegan Lake, Moira, Mongaup Valley, Monroe, Montgomery, Monticello, Montrose, Mooers, Mooers Forks, Moriah, Moriah Center, Morris, Morrisonville, Morristown, Morrisville, Mount Kisco, Mount Marion, Mount Tremper, Mount Upton, Mount Vernon, Mount Vision, Mountain Dale, Mountainville, Munnsville, Napanoch, Narrowsburg, Nassau, Natural Bridge, Nelliston, Neversink, New Baltimore, New Berlin, New Hampton, New Hartford, New Kingston, New Lebanon, New Lisbon, New Paltz, New Rochelle, New Russia, New Windsor, New York, New York Mills, Newburgh, Newcomb, Newport, Newton Falls, Nicholville, Nineveh, Niverville, Norfolk, North Bangor, North Bay, North Blenheim, North Branch, North Brookfield, North Chatham, North Creek, North Granville, North Hudson, North Lawrence, North Norwich, North Pitcher, North River, North Salem, Northville, Norwich, Norwood, Oak Hill, Obernburg, Ogdensburg, Old Chatham, Old Forge, Olivebridge, Olmstedville, Oneida, Oneonta, Oriskany, Oriskany Falls, Ossining, Oswegatchie, Otego, Otisville, Ouaquaga, Owls Head, Oxford, Palatine Bridge, Palenville, Paradox, Parishville, Parksville, Patterson, Pattersonville, Paul Smiths, Pawling, Peekskill, Pelham, Peru, Peterboro, Petersburg, Philadelphia, Phillipsport, Philmont, Phoenicia, Piercefield, Pierrepont Manor, Pine Bush, Pine Hill, Pine Island, Pine Plains, Piseco, Pitcher, Plattsburgh, Pleasant Valley, Pleasantville, Plessis, Plymouth, Poestenkill, Poland, Pond Eddy, Port Chester, Port Crane, Port Ewen, Port Henry, Port Jervis, Port Kent, Port Leyden, Porter Corners, Portlandville, Potsdam, Pottersville, Poughkeepsie, Poughquag, Pound Ridge, Prattsville, Preston Hollow, Prospect, Purchase, Purdys, Purling, Putnam Station, Putnam Valley, Queensbury, Rainbow Lake, Raquette Lake, Ravena, Ray Brook, Raymondville, Red Hook, Redford, Redwood, Remsen, Rensselaer, Rensselaer Falls, Rensselaerville, Rexford, Rhinebeck, Rhinecliff, Richfield Springs, Richmondville, Richville, Rifton, Riparius, Rock City Falls, Rock Hill, Rock Tavern, Rodman, Rome, Roscoe, Roseboom, Rosendale, Rotterdam Junction, Round Lake, Round Top, Rouses Point, Roxbury, Ruby, Russell, Rye, 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, Scarsdale, Schaghticoke, Schenectady, Schenevus, Schodack Landing, Schoharie, Schroon Lake, Schuyler Falls, Schuyler Lake, Schuylerville, Selkirk, Severance, Shandaken, Sharon Springs, Sherburne, Sherrill, Shokan, Shrub Oak, Shushan, Sidney, Sidney Center, Silver Bay, Slate Hill, Slingerlands, Sloansville, Smallwood, Smyrna, Somers, South Bethlehem, South Cairo, South Colton, South Fallsburg, South Glens Falls, South Kortright, South New Berlin, South Otselic, South Plymouth, South Salem, Southfields, Sparrow Bush, Speculator, Spencertown, Sprakers, Spring Glen, Springfield Center, Staatsburg, Stamford, Stanfordville, Star Lake, Stephentown, Sterling Forest, Stillwater, Stittville, Stone Ridge, Stony Creek, Stormville, Stottville, Stratford, Stuyvesant, Stuyvesant Falls, Summit, Summitville, Surprise, Swan Lake, Sylvan Beach, Taberg, Tannersville, Tarrytown, Thendara, Theresa, Thompson Ridge, Thompsonville, Thornwood, Thousand Island Park, Three Mile Bay, Ticonderoga, Tillson, Tivoli, Treadwell, Tribes Hill, Trout Creek, Troy, Tuckahoe, Tupper Lake, Turin, Tuxedo Park, Ulster Park, Unadilla, Unionville, Upper Jay, Utica, Valatie, Valhalla, Valley Falls, Van Hornesville, Verbank, Vermontville, Vernon, Vernon Center, Verona, Verona Beach, Verplanck, Vestal, Victory Mills, Voorheesville, Waccabuc, Waddington, Walden, Wallkill, Walton, Wampsville, Wanakena, Wappingers Falls, Warnerville, Warrensburg, Warwick, Washingtonville, Wassaic, Waterford, Watertown, Waterville, Watervliet, Wawarsing, Wellesley Island, Wells, Wells Bridge, West Burlington, West Camp, West Chazy, West Coxsackie, West Davenport, West Eaton, West Edmeston, West Fulton, West Harrison, West Hurley, West Kill, West Lebanon, West Leyden, 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, Willow, Willsboro, Wilmington, Windham, Windsor, Wingdale, Winthrop, Witherbee, Woodbourne, Woodgate, Woodridge, Woodstock, Worcester, Wurtsboro, Wynantskill, Yonkers, Yorktown Heights, Yorkville, Youngsville, Yulan

Description

Description

Health Care Plan Details

Network type	HMO
Deductible	$0 per person $0 per person
Out-of-pocket max	$2,000 per person $4,000 per family
Metal tier	Platinum

Visit Copay

Primary care visit	$15 copay
Specialist visit	$35 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$55 copay
Emergency room	$100 copay
Ambulance	$100 copay
Hospital stay (facility)	$500 copay
Hospital stay (physician)	$100 copay
Outpatient procedure (facility)	$100 copay
Outpatient procedure (physician)	$100 copay
Physical rehabilitation	$25 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay

$600 copay

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	$30 copay
Non-preferred Brand	$60 copay
Specialty	$60 copay

Lab Tests and Diagnostic Procedures

X-rays	$35 copay
Imaging (CT/PET/MRI)	$35 copay
Blood work	$35 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	$15 copay
Psychiatric hospital stay	$500 copay

Health Plan Provider Information

Health Plan Benefits

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