Plan Highlights:

No-cost annual checkups
Urgent care visits and hospital stays
Lab tests (blood tests and X-rays)
Hearing, vision, and dental^*
Maternity and newborn care
Prescription drug coverage
24/7 access to care with telemedicine
Unlimited acupuncture visits
HSA-compatible plans
Annual gym membership reimbursement**

2020
2019

Tier

Platinum Pro

Platinum Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

English

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – $20 copay

Adult – not covered

Pediatric – $20 copay

Adult - $20 copay

Vision Exams

Pediatric – $10 copay

Adult – not covered

Pediatric – $10 copay

Adult - $10 copay

$0 copay

More Plan Information

Costs & Benefits

Platinum Pro

Platinum Pro Plus

(Individual)

$2,000

(Family)

$4,000

Your Annual Checkup ()

$0 copay

$20 copay

$35 copay

Urgent Care

$50 copay

Emergency Room

$250 copay

Ambulance

$150 copay

Surgeon

$100 copay

$200 copay

$500 copay per admission

Acupuncture

$35 copay

Preventive Pediatric GuideEnglish
Women’s Preventive Services
Full List of Approved Preventive Services

Prescriptions

(Tier 1)

$10 copay

(Tier 2)

$30 copay

(Tier 3)

$60 copay

(Formulary) English

Tier

Gold Pro

Gold Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

English

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – $25 copay

Adult – not covered

Pediatric – $25 copay

Adult – $25 copay

Vision Exams

Pediatric – $10 copay

Adult – not covered

Pediatric – $10 copay

Adult – $10 copay

$0 copay

More Plan Information

Costs & Benefits

Gold Pro

Gold Pro Plus

(Individual)

$5,000

(Family)

$10,000

Your Annual Checkup ()

$0 copay

$25 copay

$40 copay

Urgent Care

$60 copay

Emergency Room

$350 copay

Ambulance

$150 copay

Surgeon

$100 copay

$300 copay

$500 copay per admission

Acupuncture

$40 copay

Prescriptions

(Tier 1)

$10 copay

(Tier 2)

$50 copay

(Tier 3)

$85 copay

(Formulary) English

Tier

Gold 25/50/0 Pro

Gold 25/50/0 Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

English

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – $25 copay

Adult – not covered

Pediatric – $25 copay

Adult – $25 copay

Vision Exams

Pediatric – $10 copay

Adult – not covered

Pediatric – $10 copay

Adult – $10 copay

$0 copay

More Plan Information

Costs & Benefits

Gold 25/50/0 Pro

Gold 25/50/0 Pro Plus

(Individual)

$7,000

(Family)

$14,000

Your Annual Checkup ()

$0 copay

$25 copay

$50 copay

Urgent Care

$60 copay

Emergency Room

$350 copay

Ambulance

$150 copay

Surgeon

$100 copay

$300 copay

$500 copay per admission

Acupuncture

$50 copay

Prescriptions

(Tier 1)

$10 copay

(Tier 2)

$50 copay

(Tier 3)

$85 copay

(Formulary) English

Tier

Silver Pro

Silver Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

English

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – $35 copay

Adult – not covered

Pediatric – $35 copay

Adult – $35 copay

Vision Exams

Pediatric – $10 copay

Adult – not covered

Pediatric – $10 copay

Adult – $10 copay

$0 copay

More Plan Information

Costs & Benefits

Silver Pro

Silver Pro Plus

(Individual)

$2,950

(Individual)

$7,900

(Family)

$5,900

(Family)

$15,800

Your Annual Checkup ()

$0 copay

$35 copay

$70 copay

Urgent Care

$70 copay

Emergency Room

$600 copay after deductible

Ambulance

$300 copay after deductible

Surgeon

$200 copay after deductible

40% coinsurance after deductible

Acupuncture

$70 copay

Prescriptions

(Tier 1)

$20 copay

(Tier 2)

$60 copay

(Tier 3)

$110 copay

(Formulary) English

Tier

Silver 40/75/4700 Pro

Silver 40/75/4700 Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

English

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – $40 copay

Adult – not covered

Pediatric – $40 copay

Adult – $40 copay

Vision Exams

Pediatric – $10 copay

Adult – not covered

Pediatric – $10 copay

Adult – $10 copay

$0 copay

More Plan Information

Costs & Benefits

Silver 40/75/4700 Pro

Silver 40/75/4700 Pro Plus

(Individual)

$4,700

(Individual)

$7,900

(Family)

$9,400

(Family)

$15,800

Your Annual Checkup ()

$0 copay

$40 copay

$75 copay

Urgent Care

$75 copay

Emergency Room

$600 copay after deductible

Ambulance

$300 copay after deductible

Surgeon

$200 copay after deductible

45% coinsurance after deductible

Acupuncture

$75 copay

Prescriptions

(Tier 1)

$20 copay

(Tier 2)

$60 copay

(Tier 3)

$110 copay

(Formulary) English

Tier

Bronze Pro

Bronze Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

English

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – 20% coinsurance after deductible

Adult – not covered

Pediatric – 20% coinsurance after deductible

Adult – 20% coinsurance after deductible

Vision Exams

Pediatric – $10 copay after deductible

Adult – not covered

Pediatric – $10 copay after deductible

Adult – $10 copay after deductible

$0 copy after deductible

More Plan Information

Costs & Benefits

Bronze Pro

Bronze Pro Plus

(Individual)

$4,000

(Individual)

$6,650

(Family)

$8,000

(Family)

$13,300

Your Annual Checkup ()

$0 copay

20% coinsurance after deductible

Urgent Care

20% coinsurance after deductible

Emergency Room

20% coinsurance after deductible

Ambulance

20% coinsurance after deductible

Surgeon

20% coinsurance after deductible

Acupuncture

20% coinsurance after deductible

Prescriptions

(Tier 1)

20% coinsurance after deductible

(Tier 2)

20% coinsurance after deductible

(Tier 3)

20% coinsurance after deductible

(Formulary) English

Tier

Bronze 6650 Pro

Bronze 6650 Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

English

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1-100 employees

Dental Cleanings

Pediatric – 0% coinsurance after deductible

Adult – not covered

Pediatric – 0% coinsurance after deductible

Adult – 0% coinsurance after deductible

Vision Exams

Pediatric – 0% coinsurance after deductible

Adult – not covered

Pediatric – 0% coinsurance after deductible

Adult – 0% coinsurance after deductible

$0 copy after deductible

More Plan Information

Costs & Benefits

Bronze 6650 Pro

Bronze 6650 Pro Plus

(Individual)

$6,650

(Individual)

$6,650

(Family)

$13,300

(Family)

$13,300

Your Annual Checkup ()

$0 copay

0% coinsurance after deductible

Urgent Care

0% coinsurance after deductible

Emergency Room

0% coinsurance after deductible

Ambulance

0% coinsurance after deductible

Surgeon

0% coinsurance after deductible

Acupuncture

0% coinsurance after deductible

Prescriptions

(Tier 1)

0% coinsurance after deductible

(Tier 2)

0% coinsurance after deductible

(Tier 3)

0% coinsurance after deductible

(Formulary) English

Tier

Platinum Pro

Platinum Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

Coming Soon

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – $20 copay

Adult – not covered

Pediatric – $20 copay

Adult - $20 copay

Vision Exams

Pediatric – $10 copay

Adult – not covered

Pediatric – $10 copay

Adult - $10 copay

$0 copay

More Plan Information

Costs & Benefits

Platinum Pro

Platinum Pro Plus

(Individual)

$2,000

(Family)

$4,000

Your Annual Checkup ()

$0 copay

$20 copay

$35 copay

Urgent Care

$50 copay

Emergency Room

$250 copay

Ambulance

$150 copay

Surgeon

$100 copay

$200 copay

$500 copay per admission

Acupuncture

$35 copay

Preventive Pediatric GuideEnglish
Women’s Preventive Services
Full List of Approved Preventive Services

Prescriptions

(Tier 1)

$10 copay

(Tier 2)

$30 copay

(Tier 3)

$60 copay

(Formulary) Coming Soon

Tier

Gold Pro

Gold Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

Coming Soon

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – $25 copay

Adult – not covered

Pediatric – $25 copay

Adult – $25 copay

Vision Exams

Pediatric – $10 copay

Adult – not covered

Pediatric – $10 copay

Adult – $10 copay

$0 copay

More Plan Information

Costs & Benefits

Gold Pro

Gold Pro Plus

(Individual)

$5,000

(Family)

$10,000

Your Annual Checkup ()

$0 copay

$25 copay

$40 copay

Urgent Care

$60 copay

Emergency Room

$350 copay

Ambulance

$150 copay

Surgeon

$100 copay

$300 copay

$500 copay per admission

Acupuncture

$40 copay

Prescriptions

(Tier 1)

$10 copay

(Tier 2)

$50 copay

(Tier 3)

$85 copay

(Formulary) Coming Soon

Tier

Gold 25/50/0 Pro

Gold 25/50/0 Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

Coming Soon

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – $25 copay

Adult – not covered

Pediatric – $25 copay

Adult – $25 copay

Vision Exams

Pediatric – $10 copay

Adult – not covered

Pediatric – $10 copay

Adult – $10 copay

$0 copay

More Plan Information

Costs & Benefits

Gold 25/50/0 Pro

Gold 25/50/0 Pro Plus

(Individual)

$7,000

(Family)

$14,000

Your Annual Checkup ()

$0 copay

$25 copay

$50 copay

Urgent Care

$60 copay

Emergency Room

$350 copay

Ambulance

$150 copay

Surgeon

$100 copay

$300 copay

$500 copay per admission

Acupuncture

$50 copay

Prescriptions

(Tier 1)

$10 copay

(Tier 2)

$50 copay

(Tier 3)

$85 copay

(Formulary) Coming Soon

Tier

Silver Pro

Silver Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

Coming Soon

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – $35 copay

Adult – not covered

Pediatric – $35 copay

Adult – $35 copay

Vision Exams

Pediatric – $10 copay

Adult – not covered

Pediatric – $10 copay

Adult – $10 copay

$0 copay

More Plan Information

Costs & Benefits

Silver Pro

Silver Pro Plus

(Individual)

$4,300

(Individual)

$8,150

(Family)

$8,600

(Family)

$16,300

Your Annual Checkup ()

$0 copay

$35 copay

$70 copay

Urgent Care

$70 copay

Emergency Room

$600 copay after deductible

Ambulance

$300 copay after deductible

Surgeon

$200 copay after deductible

40% coinsurance after deductible

Acupuncture

$70 copay

Prescriptions

(Tier 1)

$20 copay

(Tier 2)

$60 copay

(Tier 3)

$110 copay

(Formulary) Coming Soon

Tier

Silver 40/75/4700 Pro

Silver 40/75/4700 Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

Coming Soon

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – $40 copay

Adult – not covered

Pediatric – $40 copay

Adult – $40 copay

Vision Exams

Pediatric – $10 copay

Adult – not covered

Pediatric – $10 copay

Adult – $10 copay

$0 copay

More Plan Information

Costs & Benefits

Silver 40/75/4700 Pro

Silver 40/75/4700 Pro Plus

(Individual)

$4,700

(Individual)

$7,900

(Family)

$9,400

(Family)

$15,800

Your Annual Checkup ()

$0 copay

$40 copay

$75 copay

Urgent Care

$75 copay

Emergency Room

$600 copay after deductible

Ambulance

$300 copay after deductible

Surgeon

$200 copay after deductible

45% coinsurance after deductible

Acupuncture

$75 copay

Prescriptions

(Tier 1)

$20 copay

(Tier 2)

$60 copay

(Tier 3)

$110 copay

(Formulary) Coming Soon

Tier

Bronze Pro

Bronze Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

Coming Soon

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1–100 employees

Dental Cleanings

Pediatric – 20% coinsurance after deductible

Adult – not covered

Pediatric – 20% coinsurance after deductible

Adult – 20% coinsurance after deductible

Vision Exams

Pediatric – $10 copay after deductible

Adult – not covered

Pediatric – $10 copay after deductible

Adult – $10 copay after deductible

$0 copy after deductible

More Plan Information

Costs & Benefits

Bronze Pro

Bronze Pro Plus

(Individual)

$4,500

(Individual)

$6,750

(Family)

$9,000

(Family)

$13,500

Your Annual Checkup ()

$0 copay

20% coinsurance after deductible

Urgent Care

20% coinsurance after deductible

Emergency Room

20% coinsurance after deductible

Ambulance

20% coinsurance after deductible

Surgeon

20% coinsurance after deductible

Acupuncture

20% coinsurance after deductible

Prescriptions

(Tier 1)

20% coinsurance after deductible

(Tier 2)

20% coinsurance after deductible

(Tier 3)

20% coinsurance after deductible

(Formulary) Coming Soon

Tier

Bronze 6650 Pro

Bronze 6650 Pro Plus

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

Coming Soon

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1-100 employees

Dental Cleanings

Pediatric – 0% coinsurance after deductible

Adult – not covered

Pediatric – 0% coinsurance after deductible

Adult – 0% coinsurance after deductible

Vision Exams

Pediatric – 0% coinsurance after deductible

Adult – not covered

Pediatric – 0% coinsurance after deductible

Adult – 0% coinsurance after deductible

$0 copy after deductible

More Plan Information

Costs & Benefits

Bronze 6650 Pro

Bronze 6650 Pro Plus

(Individual)

$6,650

(Individual)

$6,650

(Family)

$13,300

(Family)

$13,300

Your Annual Checkup ()

$0 copay

0% coinsurance after deductible

Urgent Care

0% coinsurance after deductible

Emergency Room

0% coinsurance after deductible

Ambulance

0% coinsurance after deductible

Surgeon

0% coinsurance after deductible

Acupuncture

0% coinsurance after deductible

Prescriptions

(Tier 1)

0% coinsurance after deductible

(Tier 2)

0% coinsurance after deductible

(Tier 3)

0% coinsurance after deductible

(Formulary) Coming Soon

Tier

Bronze 8150 Pro

Summary of Benefits and Coverage (PDF)

Comprehensive Formulary

Comprehensive Formulary (List of Covered Drugs)

Coming Soon

Monthly premium costs depend on household size. Get a Quote

Other Eligibility Requirements

Small business with 1-100 employees

Dental Cleanings

Pediatric – 0% coinsurance after deductible

Adult – not covered

Vision Exams

Pediatric – 0% coinsurance after deductible

Adult – not covered

$0 copy after deductible

More Plan Information

Costs & Benefits

Bronze 8150 Pro

(Individual)

$8,150

(Individual)

$8,150

(Family)

$16,300

(Family)

$16,300

Your Annual Checkup ()

$0 copay

0% coinsurance after deductible

Urgent Care

0% coinsurance after deductible

Emergency Room

0% coinsurance after deductible

Ambulance

0% coinsurance after deductible

Surgeon

0% coinsurance after deductible

Acupuncture

0% coinsurance after deductible

Prescriptions

(Tier 1)

0% coinsurance after deductible

(Tier 2)

0% coinsurance after deductible

(Tier 3)

0% coinsurance after deductible

(Formulary) Coming Soon

^*Available with the Pro Plus Plan.

^**Up to $200 per reward period. There are two reward cycles—January through June, and July through December.

The benefit information provided is a brief summary, not a complete description, of benefits. For more information, contact the plan.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”). Plans contain exclusions and limitations.

Additional Benefits

24/7 Access to Telemedicine with Teladoc^*

Talk to a doctor anytime—for a $0 copay. Connect with board-certified doctors through video chat or phone for prescriptions, help diagnosing and treating non-emergency conditions, and more. Access to dermatologists is also available.
Urgent Care Center Network

Get the care you need when you need it at an urgent care center in our network–no appointment needed. Urgent care centers offer late-night and weekend hours, often with faster service at a lower cost than the Emergency Room (ER).

Visit an in-network urgent care center to get help for non-emergency conditions like earache, upset stomach, sprains, stitches, and more.
Active & Fit Direct

Working out just got cheaper. 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, monitor your progress, achieve your fitness goals, and so much more.

Please note: a three-month membership commitment is required up front. Learn more about Active & Fit Direct.
Rewards for Working Out

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 a qualifying gym or fitness facility at least 50 times in a six-month period and track your workouts. 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!

^*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 periods—January through June, and July through December.

^†Up to $100 per reward period. There are two reward periods—January through June, and July through December.