Silver Leaf 200-250
Silver Leaf Premier 200-250
Silver Leaf Premier Plus 200-250
Premium
Monthly premium costs depend on household income and size
Deductible
(Individual)
Silver Leaf 200-250
$3,050
Silver Leaf Premier 200-250
$4,250
Silver Leaf Premier Plus 200-250
$2,160
Deductible (Family)
Silver Leaf 200-250
$6,100
Silver Leaf Premier 200-250
$8,500
Silver Leaf Premier Plus 200-250
$4,320
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 200-250
$9,600
Silver Leaf Premier 200-250
$8,900
Silver Leaf Premier Plus 200-250
$8,600
Maximum Out-of-Pocket (Family)
Silver Leaf 200-250
$19,200
Silver Leaf Premier 200-250
$17,800
Silver Leaf Premier Plus 200-250
$17,200
Your Annual Checkup
Silver Leaf 200-250
$0 copay
Silver Leaf Premier 200-250
$0 copay
Silver Leaf Premier Plus 200-250
$0 copay
Primary Care Provider (PCP) Visit
Silver Leaf 200-250
$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 200-250
$35 copay not subject to deductible
Silver Leaf Premier Plus 200-250
$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 200-250
not covered
Silver Leaf Premier 200-250
$35 copay not subject to deductible
Silver Leaf Premier Plus 200-250
$35 copay not subject to deductible
Dental Pediatrics (up to Age 19)
Silver Leaf 200-250
$30 copay after deductible
Silver Leaf Premier 200-250
$35 copay not subject to deductible
Silver Leaf Premier Plus 200-250
$35 copay not subject to deductible
Vision Exams Adult
Silver Leaf 200-250
not covered
Silver Leaf Premier 200-250
$35 copay after deductible
Silver Leaf Premier Plus 200-250
$35 copay after deductible
Vision Exams Pediatrics (up to Age 19)
Silver Leaf 200-250
$30 copay after deductible
Silver Leaf Premier 200-250
$35 copay after deductible
Silver Leaf Premier Plus 200-250
$35 copay after deductible
Telemedicine
(Teladoc Health®)
Silver Leaf 200-250
$0 copay
Silver Leaf Premier 200-250
$0 copay
Silver Leaf Premier Plus 200-250
$0 copay
Specialist Visit
Silver Leaf 200-250
$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 200-250
$55 copay after deductible
Silver Leaf Premier Plus 200-250
$70 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)
$70 copay after deductible for additional visits
Retail Health Clinic
Silver Leaf 200-250
$30 copay after deductible
Silver Leaf Premier 200-250
$35 copayment not subject to deductible
Silver Leaf Premier Plus 200-250
$35 copay not subject to deductible
Urgent Care
Silver Leaf 200-250
$70 copay after deductible
Silver Leaf Premier 200-250
$70 copay after deductible
Silver Leaf Premier Plus 200-250
$70 copay after deductible
Emergency Room
Silver Leaf 200-250
$275 copay after deductible
Silver Leaf Premier 200-250
$550 copay after deductible
Silver Leaf Premier Plus 200-250
$750 copay after deductible
Ambulance
Silver Leaf 200-250
$150 copay after deductible
Silver Leaf Premier 200-250
$150 copay after deductible
Silver Leaf Premier Plus 200-250
$150 copay after deductible
Surgeon
Silver Leaf 200-250
$150 copay after deductible
Silver Leaf Premier 200-250
$250 copay after deductible
Silver Leaf Premier Plus 200-250
$250 copay after deductible
Outpatient Facility
Silver Leaf 200-250
$150 copay after deductible
Silver Leaf Premier 200-250
$250 copay after deductible
Silver Leaf Premier Plus 200-250
$250 copay after deductible
Inpatient Hospital Stay
Silver Leaf 200-250
$1,500 copay per admission after deductible
Silver Leaf Premier 200-250
$1,500 copay per admission after deductible
Silver Leaf Premier Plus 200-250
$2,050 copay per admission after deductible