| Covered Benefits (Individual and Family) | ||||
| Federal Poverty Level (FPL) | >250% FPL | 200% – 250% FPL | 150% – 200% FPL* | 100% – 150% FPL* |
| Your Annual Checkup (Preventive Care) | $0 – No deductible or cost sharing applies to recommended preventive care visits or services | |||
| Primary Care Provider (PCP) Visit | $30 copay after deductible | $30 copay after deductible | $15 copay after deductible | $10 copay |
| Specialist Visit | $50 copay after deductible | $50 copay after deductible | $35 copay after deductible | $20 copay |
| Urgent Care | $70 copay after deductible | $70 copay after deductible | $50 copay after deductible | $30 copay |
| Emergency Room | $250 copay after deductible | $250 copay after deductible | $75 copay after deductible | $50 copay |
| Ambulance | $150 copay after deductible | $150 copay after deductible | $75 copay after deductible | $50 copay |
| Surgeon | $100 copay after deductible | $100 copay after deductible | $75 copay after deductible | $25 copay |
| Outpatient Facility | $100 copay after deductible | $100 copay after deductible | $75 copay after deductible | $25 copay |
| Inpatient Facility/Skilled Nursing Facility | $1,500 per admission after deductible | $1,500 per admission after deductible | $250 per admission after deductible | $100 per admission |
| Physical, Occupational, and Speech Therapies | $30 copay after deductible | $30 copay after deductible | $25 copay after deductible | $15 copay |
| Pediatric Dental Care | $30 copay after deductible | $30 copay after deductible | $15 copay after deductible | $10 copay |
| Pediatric Vision Exams | $30 copay after deductible | $30 copay after deductible | $15 copay after deductible | $10 copay |
The benefit information given above is a brief summary, not a full description, of benefits.
For more information, please click the links below:
Silver Leaf plan > 250% FPL (English / Español / 中文)
Silver Leaf plan 200% – 250% FPL (English / Español / 中文)
Silver Leaf plan 150% – 200% FPL (English / Español / 中文)
Silver Leaf plan 100% – 150% FPL (English / Español / 中文)
For help with terms like deductible and copay, please visit the Glossary.
*Available only to people age 65 and older who are not eligible for Medicare.
The benefit information given is a brief summary, not a full description, of benefits. For more information, contact the plan.
La información de los beneficios proporcionada es un resumen breve, no una descripción completa de los beneficios. Para más información, comuníquese con el plan.
此處提供的福利資料只是摘要，並非福利的完整說明。詳情請與本計劃聯絡
Based on your income, you can get help to reduce the costs of your Silver Leaf plan. This help is also called a “subsidy.” Subsidies are available to families with incomes up to 250% of the Federal Poverty Level (FPL). Click here to view 2018 FPL amounts.
Use the grid below to see what your deductible, coinsurance, and maximum out-of-pocket costs will be for the Silver Leaf plan. As an example, if your income is 200% of FPL, your deductible will be $1,650 and your yearly maximum out-of-pocket cost will be $5,700.
For help with terms like deductible and maximum out-of-pocket, please visit the Glossary.
| Cost (Individual) | ||||
| Federal Poverty Level (FPL) | >250% FPL | 200% – 250% FPL | 150% – 200% FPL* | 100% – 150% FPL* |
| Medical Deductible | $1,700 | $1,350 | $250 | $0 |
| Maximum Out-of-Pocket | $7,500 | $6,075 | $2,100 | $1,000 |
| Cost (Family) | ||||
| Federal Poverty Level (FPL) | > 250% FPL | 200% – 250% FPL | 150% – 200% FPL* | 100% – 150% FPL* |
| Medical Deductible | $3,400 | $2,700 | $500 | $0 |
| Maximum Out-of-Pocket |
$15,000 | $12,150 | $4,200 | $2,000 |
*Available only to people age 65 and older who are not eligible for Medicare.
| Prescription Drugs (Individual and Family) | ||||
| Federal Poverty Level (FPL) | > 250% FPL | 200% – 250% FPL | 150% – 200% FPL* | 100% – 150% FPL* |
| Generic (Tier 1) |
$10 copay | $10 copay | $9 copay | $6 copay |
| Brand Name Preferred (Tier 2) |
$35 copay | $35 copay | $20 copay | $15 copay |
| Brand Name Non-Preferred (Tier 3) |
$70 copay | $70 copay | $40 copay | $30 copay |
| 90-Day Mail-Order Supply for Generic (Tier 1) |
$25 copay | $25 copay | $22.50 copay | $15 copay |
2019 Leaf Plan Comprehensive Formulary
*Available only to people age 65 and older who are not eligible for Medicare.
24/7 Access to Telemedicine with Teladoc*
Talk to a doctor any time—for a $0 copay! Visit with board-certified doctors through video chat or phone for prescriptions, treatment of non-emergency health issues, and more! Dermatology visits are also available.
Urgent Care Center Network
Get the care you need when you need it at an urgent care center in our network! Urgent care centers offer late-night and weekend hours, plus faster service at a lower cost than the emergency room (ER). Plus, you don’t need an appointment.
Visit an in-network urgent care center to get help with non-emergency health issues like earache, upset stomach, and sprains; for wounds that need stitches; and more.
Rewards for Working Out
As a Leaf plan member, you can get rewarded for taking care of your health—up to $400 in a calendar year with the ExerciseRewards™ program.**
It’s easy! Work out at qualifying gym or fitness facility at least 50 times in a six-month period and track your workouts in three ways:
Your spouse or domestic partner can be reimbursed too—up to $200 in a calendar year when he or she works out at least 50 times each six-month period in a calendar year.‡
Learn more about ExerciseRewards™ or start earning your reward now!
Introducing Active&Fit Direct
Working out just got easier. For just $25/month plus a one-time enrollment fee of $25, you can get a standard membership to a fitness center in your area. Track your activity, check your progress, reach your fitness goals, and so much more!
Please note: a three-month membership commitment is required up front. Learn more about Active&Fit Direct.
*Telemedicine isn’t a replacement for your Primary Care Provider (PCP). Your PCP should always be your first choice for care and for routine visits.
**Up to $200 per reward period. There are two reward cycles—January through June, and July through December.
†Tell your fitness facility that you would like them to send your visits to the ExerciseRewards program on your behalf.
‡Up to $100 per reward period. There are two reward periods—January through June, and July through December.
We can help you find a plan that’s right for you. You can:
You can also go to the NY State of Health website to view your choices, or call the NY State of Health customer service center at 1-855-355-5777.
