Silver Leaf
Silver Leaf Premier
Silver Leaf Premier Plus
Premium
Monthly premium costs depend on household income and size
Deductible
(individual)
Silver Leaf
$2,160
Silver Leaf Premier
$4,000
Silver Leaf Premier Plus
$2,050
Deductible (Family)
Silver Leaf
$4,320
Silver Leaf Premier
$8,000
Silver Leaf Premier Plus
$4,100
Eligible Age
Under 65
Under 65
Under 65
Eligible Service Areas
Within New York City’s five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Long Island, and Westchester.
Maximum Out-of-Pocket
(individual)
Silver Leaf
$8,100
Silver Leaf Premier
$7,900
Silver Leaf Premier Plus
$7,650
Maximum Out-of-Pocket (Family)
Silver Leaf
$16,200
Silver Leaf Premier
$15,800
Silver Leaf Premier Plus
$15,300
Your Annual Checkup
Silver Leaf
$0 copay
Silver Leaf Premier
$0 copay
Silver Leaf Premier Plus
$0 copay
Primary Care Provider (PCP) Visit
Silver Leaf
$30 copay not subject to deductible for the first visit (PCP, specialist, outpatient mental health/substance use disorder, chiropractor, allergy, Applied Behavioral Analysis (ABA), or second-opinion visit)
$30 copay after deductible for additional visits
Silver Leaf Premier
$35 copay not subject to deductible
Silver Leaf Premier Plus
$35 copay not subject to deductible for the first visit (PCP, specialist, outpatient mental health/substance use disorder, chiropractor, allergy, Applied Behavioral Analysis (ABA), or second-opinion visit)
$30 copay after deductible for additional visits
Dental Care Adult
Silver Leaf
not covered
Silver Leaf Premier
$35 copay not subject to deductible
Silver Leaf Premier Plus
$35 copay not subject to deductible
Dental Pediatrics (up to Age 19)
Silver Leaf
$30 copay after deductible
Silver Leaf Premier
$35 copay not subject to deductible
Silver Leaf Premier Plus
$35 copay not subject to deductible
Vision Exams Adult
Silver Leaf
not covered
Silver Leaf Premier
$35 copay after deductible
Silver Leaf Premier Plus
$35 copay after deductible
Vision Exams Pediatrics (up to Age 19)
Silver Leaf
$30 copay after deductible
Silver Leaf Premier
$35 copay after deductible
Silver Leaf Premier Plus
$35 copay after deductible
Telemedicine
(Teladoc)
Silver Leaf
$0 copay
Silver Leaf Premier
$0 copay
Silver Leaf Premier Plus
$0 copay
Specialist Visit
Silver Leaf
$65 copay not subject to deductible for the first visit (PCP, specialist, outpatient mental health/substance use disorder, chiropractor, allergy, Applied Behavioral Analysis (ABA), or second-opinion visit)
$65 copay after deductible for additional visits
Silver Leaf Premier
$65 copay after deductible
Silver Leaf Premier Plus
$75 copay not subject to deductible for the first visit (PCP, specialist, outpatient mental health/substance use disorder, chiropractor, allergy, Applied Behavioral Analysis (ABA), or second-opinion visit)
$65 copay after deductible for additional visits
Retail Health Clinic
Silver Leaf
$30 copay after deductible
Silver Leaf Premier
$35 copayment not subject to deductible
Silver Leaf Premier Plus
$35 copay not subject to deductible
Urgent Care
Silver Leaf
$70 copay after deductible
Silver Leaf Premier
$70 copay after deductible
Silver Leaf Premier Plus
$70 copay after deductible
Emergency Room
Silver Leaf
$275 copay after deductible
Silver Leaf Premier
$500 copay after deductible
Silver Leaf Premier Plus
$500 copay after deductible
Ambulance
Silver Leaf
$150 copay after deductible
Silver Leaf Premier
$150 copay after deductible
Silver Leaf Premier Plus
$150 copay after deductible
Surgeon
Silver Leaf
$150 copay after deductible
Silver Leaf Premier
$150 copay after deductible
Silver Leaf Premier Plus
$150 copay after deductible
Outpatient Facility
Silver Leaf
$150 copay after deductible
Silver Leaf Premier
$150 copay after deductible
Silver Leaf Premier Plus
$150 copay after deductible
Inpatient Hospital Stay
Silver Leaf
$1,500 copay per admission after deductible
Silver Leaf Premier
$1,500 copay per admission after deductible
Silver Leaf Premier Plus
$1,500 copay per admission after deductible