Plan Highlights:
No-cost annual checkups
Hospital stays, emergency room, urgent care, and retail health clinic visits
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 (Teladoc)
Unlimited acupuncture visits
HSA-compatible plans
Annual gym membership reimbursement**
Plans
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Long Island, Westchester, and Rockland counties
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Deductible (Individual)
$0
$0
Maximum Out-of-Pocket (Individual)
$2,000
$2,000
Maximum Out-of-Pocket (Family)
$4,000
$4,000
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$20 copay
$20 copay
Specialist Visit
$35 copay
$35 copay
Retail Health Clinic
$20 copay
$20 copay
Urgent Care
$50 copay
$50 copay
Emergency Room
$250 copay
$250 copay
Ambulance
$150 copay
$150 copay
Surgeon
$100 copay
$100 copay
Outpatient Facility
$200 copay
$200 copay
Inpatient Hospital Stay
$500 copay per admission
$500 copay per admission
Acupuncture
$35 copay
$35 copay
Generic Drugs (Tier 1)
$10 copay
$10 copay
Brand Name Preferred (Tier 2)
$30 copay
$30 copay
Brand Name Non-Preferred (Tier 3)
$60 copay
$60 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$20 copay
$20 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Long Island, Westchester, and Rockland counties
Other Eligibility Requirements
Small business with 1–100 employees
Dental Cleanings
Pediatric – $25 copay
Adult –$25 copay
Vision Exams
Pediatric – $10 copay
Adult – $10 copay
Telemedicine (Teladoc )
$0 copay
Deductible (Individual)
$1,350
Maximum Out-of-Pocket (Individual)
$8,150
Deductible (Family)
$2,700
Maximum Out-of-Pocket (Family)
$16,300
Your Annual Checkup (Preventive Care )
$0 copay
Primary Care Provider (PCP) Visit
$25 copay
Specialist Visit
$70 copay
Retail Health Clinic
$25 copay
Emergency Room
$600 copay after deductible
Surgeon
20% coinsurance after deductible
Outpatient Facility
20% coinsurance after deductible
Inpatient Hospital Stay
20% coinsurance after deductible
Generic Drugs (Tier 1)
$20 copay
Brand Name Preferred (Tier 2)
$60 copay
Brand Name Non-Preferred (Tier 3)
$110 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$40 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Long Island, Westchester, and Rockland counties
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Deductible (Individual)
$4,300
$4,300
Maximum Out-of-Pocket (Individual)
$8,150
$8,150
Deductible (Family)
$8,600
$8,600
Maximum Out-of-Pocket (Family)
$16,300
$16,300
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$35 copay
$35 copay
Specialist Visit
$70 copay
$70 copay
Retail Health Clinic
$35 copay
$35 copay
Urgent Care
$70 copay
$70 copay
Emergency Room
$600 copay after deductible
$600 copay after deductible
Ambulance
$300 copay after deductible
$300 copay after deductible
Surgeon
$200 copay
$200 copay
Outpatient Facility
40% coinsurance after deductible
40% coinsurance after deductible
Inpatient Hospital Stay
40% coinsurance per admission after deductible
40% coinsurance per admission after deductible
Acupuncture
$70 copay
$70 copay
Generic Drugs (Tier 1)
$20 copay
$20 copay
Brand Name Preferred (Tier 2)
$60 copay
$60 copay
Brand Name Non-Preferred (Tier 3)
$110 copay
$110 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$40 copay
$40 copay
Covered Prescription Drugs (Formulary)
English
Tier
Silver 40/75/4700 Pro Plus
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Long Island, Westchester, and Rockland counties
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Silver 40/75/4700 Pro Plus
Deductible (Individual)
$4,700
$4,700
Maximum Out-of-Pocket (Individual)
$7,900
$7,900
Deductible (Family)
$9,400
$9,400
Maximum Out-of-Pocket (Family)
$15,800
$15,800
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$40 copay
$40 copay
Specialist Visit
$75 copay
$75 copay
Retail Health Clinic
$40 copay
$40 copay
Urgent Care
$75 copay
$75 copay
Emergency Room
$600 copay after deductible
$600 copay after deductible
Ambulance
$300 copay after deductible
$300 copay after deductible
Surgeon
$200 copay
$200 copay
Outpatient Facility
45% coinsurance after deductible
45% coinsurance after deductible
Inpatient Hospital Stay
45% coinsurance per admission after deductible
45% coinsurance per admission after deductible
Acupuncture
$75 copay
$75 copay
Generic Drugs (Tier 1)
$20 copay
$20 copay
Brand Name Preferred (Tier 2)
$60 copay
$60 copay
Brand Name Non-Preferred (Tier 3)
$110 copay
$110 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$40 copay
$40 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Long Island, Westchester, and Rockland counties
Other Eligibility Requirements
Small business with 1–100 employees
Dental Cleanings
Pediatric – 50% coinsurance after deductible
Adult – not covered
Pediatric – 50% coinsurance after deductible
Adult – 50% coinsurance after deductible
Vision Exams
Pediatric – $10 copay after deductible
Adult – not covered
Pediatric – $10 copay after deductible
Adult – $10 copay after deductible
Telemedicine (Teladoc )
$0 copy after deductible
$0 copy after deductible
Deductible (Individual)
$5,950
$5,950
Maximum Out-of-Pocket (Individual)
$6,900
$6,900
Deductible (Family)
$11,900
$11,900
Maximum Out-of-Pocket (Family)
$13,800
$13,800
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
50% coinsurance after deductible
50% coinsurance after deductible
Specialist Visit
50% coinsurance after deductible
50% coinsurance after deductible
Retail Health Clinic
50% coinsurance after deductible
50% coinsurance after deductible
Urgent Care
50% coinsurance after deductible
50% coinsurance after deductible
Emergency Room
50% coinsurance after deductible
50% coinsurance after deductible
Ambulance
50% coinsurance after deductible
50% coinsurance after deductible
Surgeon
50% coinsurance after deductible
50% coinsurance after deductible
Outpatient Facility
50% coinsurance after deductible
50% coinsurance after deductible
Inpatient Hospital Stay
50% coinsurance per admission after deductible
50% coinsurance per admission after deductible
Acupuncture
50% coinsurance after deductible
50% coinsurance after deductible
Generic Drugs (Tier 1)
50% coinsurance after deductible
50% coinsurance after deductible
Brand Name Preferred (Tier 2)
50% coinsurance after deductible
50% coinsurance after deductible
Brand Name Non-Preferred (Tier 3)
50% coinsurance after deductible
50% coinsurance after deductible
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Long Island, Westchester, and Rockland counties
Other Eligibility Requirements
Small business with 1–100 employees
Dental Cleanings
Pediatric – 50% coinsurance after deductible
Adult – not covered
Vision Exams
Pediatric – 50% coinsurance after deductible
Adult – not covered
Telemedicine (Teladoc )
$0 copay
Deductible (Individual)
$5,250
Maximum Out-of-Pocket (Individual)
$8,550
Deductible (Family)
$10,500
Maximum Out-of-Pocket (Family)
$17,100
Your Annual Checkup (Preventive Care )
$0 copay
Primary Care Provider (PCP) Visit
$0 copay for first 3 visits (any combination of PCP or outpatient mental health/substance use disorder) 50% coinsurance after deductible for additional visits
Specialist Visit
50% coinsurance after deductible
Retail Health Clinic
50% coinsurance after deductible
Urgent Care
50% coinsurance after deductible
Emergency Room
50% coinsurance after deductible
Ambulance
50% coinsurance after deductible
Surgeon
50% coinsurance after deductible
Outpatient Facility
50% coinsurance after deductible
Inpatient Hospital Stay
50% coinsurance per admission after deductible
Acupuncture
50% coinsurance after deductible
Generic Drugs (Tier 1)
50% coinsurance after deductible
Brand Name Preferred (Tier 2)
50% coinsurance after deductible
Brand Name Non-Preferred (Tier 3)
50% coinsurance after deductible
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Long Island, Westchester, and Rockland counties
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
Telemedicine (Teladoc )
$0 copy after deductible
$0 copy after deductible
Deductible (Individual)
$6,850
$6,850
Maximum Out-of-Pocket (Individual)
$6,850
$6,850
Deductible (Family)
$13,700
$13,700
Maximum Out-of-Pocket (Family)
$13,700
$13,700
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
0% coinsurance after deductible
0% coinsurance after deductible
Specialist Visit
0% coinsurance after deductible
0% coinsurance after deductible
Retail Health Clinic
0% coinsurance after deductible
0% coinsurance after deductible
Urgent Care
0% coinsurance after deductible
0% coinsurance after deductible
Emergency Room
0% coinsurance after deductible
0% coinsurance after deductible
Ambulance
0% coinsurance after deductible
0% coinsurance after deductible
Surgeon
0% coinsurance after deductible
0% coinsurance after deductible
Outpatient Facility
0% coinsurance after deductible
0% coinsurance after deductible
Inpatient Hospital Stay
0% coinsurance per admission after deductible
0% coinsurance per admission after deductible
Acupuncture
0% coinsurance after deductible
0% coinsurance after deductible
Generic Drugs (Tier 1)
0% coinsurance after deductible
0% coinsurance after deductible
Brand Name Preferred (Tier 2)
0% coinsurance after deductible
0% coinsurance after deductible
Brand Name Non-Preferred (Tier 3)
0% coinsurance after deductible
0% coinsurance after deductible
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Long Island, Westchester, and Rockland counties
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
Telemedicine (Teladoc )
0% copay
Deductible (Individual)
$8,225
Maximum Out-of-Pocket (Individual)
$8,225
Deductible (Family)
$16,450
Maximum Out-of-Pocket (Family)
$16,450
Your Annual Checkup (Preventive Care )
$0 copay
Primary Care Provider (PCP) Visit
0% coinsurance after deductible
Specialist Visit
0% coinsurance after deductible
Retail Health Clinic
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
Outpatient Facility
0% coinsurance after deductible
Inpatient Hospital Stay
0% coinsurance per admission after deductible
Acupuncture
0% coinsurance after deductible
Generic Drugs (Tier 1)
0% coinsurance after deductible
Brand Name Preferred (Tier 2)
0% coinsurance after deductible
Brand Name Non-Preferred (Tier 3)
0% coinsurance after deductible
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Deductible (Individual)
$0
$0
Maximum Out-of-Pocket (Individual)
$2,000
$2,000
Maximum Out-of-Pocket (Family)
$4,000
$4,000
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$20 copay
$20 copay
Specialist Visit
$35 copay
$35 copay
Retail Health Clinic
$20 copay
$20 copay
Urgent Care
$50 copay
$50 copay
Emergency Room
$250 copay
$250 copay
Ambulance
$150 copay
$150 copay
Surgeon
$100 copay
$100 copay
Outpatient Facility
$200 copay
$200 copay
Inpatient Hospital Stay
$500 copay per admission
$500 copay per admission
Acupuncture
$35 copay
$35 copay
Generic Drugs (Tier 1)
$10 copay
$10 copay
Brand Name Preferred (Tier 2)
$30 copay
$30 copay
Brand Name Non-Preferred (Tier 3)
$60 copay
$60 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$20 copay
$20 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Deductible (Individual)
$0
$0
Maximum Out-of-Pocket (Individual)
$2,000
$2,000
Maximum Out-of-Pocket (Family)
$4,000
$4,000
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$20 copay
$20 copay
Specialist Visit
$35 copay
$35 copay
Retail Health Clinic
$20 copay
$20 copay
Urgent Care
$50 copay
$50 copay
Emergency Room
$250 copay
$250 copay
Ambulance
$150 copay
$150 copay
Surgeon
$100 copay
$100 copay
Outpatient Facility
$200 copay
$200 copay
Inpatient Hospital Stay
$500 copay per admission
$500 copay per admission
Acupuncture
$35 copay
$35 copay
Generic Drugs (Tier 1)
$10 copay
$10 copay
Brand Name Preferred (Tier 2)
$30 copay
$30 copay
Brand Name Non-Preferred (Tier 3)
$60 copay
$60 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$20 copay
$20 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Deductible (Individual)
$0
$0
Maximum Out-of-Pocket (Individual)
$5,250
$5,250
Maximum Out-of-Pocket (Family)
$10,500
$10,500
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$25 copay
$25 copay
Specialist Visit
$40 copay
$40 copay
Retail Health Clinic
$25 copay
$25 copay
Urgent Care
$60 copay
$60 copay
Emergency Room
$350 copay
$350 copay
Ambulance
$150 copay
$150 copay
Surgeon
$100 copay
$100 copay
Outpatient Facility
$300 copay
$300 copay
Inpatient Hospital Stay
$500 copay per admission
$500 copay per admission
Acupuncture
$40 copay
$40 copay
Generic Drugs (Tier 1)
$10 copay
$10 copay
Brand Name Preferred (Tier 2)
$50 copay
$50 copay
Brand Name Non-Preferred (Tier 3)
$85 copay
$85 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$20 copay
$20 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Deductible (Individual)
$0
$0
Maximum Out-of-Pocket (Individual)
$5,250
$5,250
Maximum Out-of-Pocket (Family)
$10,500
$10,500
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$25 copay
$25 copay
Specialist Visit
$40 copay
$40 copay
Retail Health Clinic
$25 copay
$25 copay
Urgent Care
$60 copay
$60 copay
Emergency Room
$350 copay
$350 copay
Ambulance
$150 copay
$150 copay
Surgeon
$100 copay
$100 copay
Outpatient Facility
$300 copay
$300 copay
Inpatient Hospital Stay
$500 copay per admission
$500 copay per admission
Acupuncture
$40 copay
$40 copay
Generic Drugs (Tier 1)
$10 copay
$10 copay
Brand Name Preferred (Tier 2)
$50 copay
$50 copay
Brand Name Non-Preferred (Tier 3)
$85 copay
$85 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$20 copay
$20 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Deductible (Individual)
$0
$0
Maximum Out-of-Pocket (Individual)
$7,000
$7,000
Maximum Out-of-Pocket (Family)
$14,000
$14,000
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$25 copay
$25 copay
Specialist Visit
$50 copay
$50 copay
Retail Health Clinic
$25 copay
$25 copay
Urgent Care
$60 copay
$60 copay
Emergency Room
$350 copay
$350 copay
Ambulance
$150 copay
$150 copay
Surgeon
$100 copay
$100 copay
Outpatient Facility
$300 copay
$300 copay
Inpatient Hospital Stay
$500 copay per admission
$500 copay per admission
Acupuncture
$50 copay
$50 copay
Generic Drugs (Tier 1)
$10 copay
$10 copay
Brand Name Preferred (Tier 2)
$50 copay
$50 copay
Brand Name Non-Preferred (Tier 3)
$85 copay
$85 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$20 copay
$20 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Deductible (Individual)
$0
$0
Maximum Out-of-Pocket (Individual)
$7,000
$7,000
Maximum Out-of-Pocket (Family)
$14,000
$14,000
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$25 copay
$25 copay
Specialist Visit
$50 copay
$50 copay
Retail Health Clinic
$25 copay
$25 copay
Urgent Care
$60 copay
$60 copay
Emergency Room
$350 copay
$350 copay
Ambulance
$150 copay
$150 copay
Surgeon
$100 copay
$100 copay
Outpatient Facility
$300 copay
$300 copay
Inpatient Hospital Stay
$500 copay per admission
$500 copay per admission
Acupuncture
$50 copay
$50 copay
Generic Drugs (Tier 1)
$10 copay
$10 copay
Brand Name Preferred (Tier 2)
$50 copay
$50 copay
Brand Name Non-Preferred (Tier 3)
$85 copay
$85 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$20 copay
$20 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Deductible (Individual)
$4,300
$4,300
Maximum Out-of-Pocket (Individual)
$8,150
$8,150
Deductible (Family)
$8,600
$8,600
Maximum Out-of-Pocket (Family)
$16,300
$16,300
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$35 copay
$35 copay
Specialist Visit
$70 copay
$70 copay
Retail Health Clinic
$35 copay
$35 copay
Urgent Care
$70 copay
$70 copay
Emergency Room
$600 copay after deductible
$600 copay after deductible
Ambulance
$300 copay after deductible
$300 copay after deductible
Surgeon
$200 copay after deductible
$200 copay after deductible
Outpatient Facility
40% coinsurance after deductible
40% coinsurance after deductible
Inpatient Hospital Stay
40% coinsurance per admission after deductible
40% coinsurance per admission after deductible
Acupuncture
$70 copay
$70 copay
Generic Drugs (Tier 1)
$20 copay
$20 copay
Brand Name Preferred (Tier 2)
$60 copay
$60 copay
Brand Name Non-Preferred (Tier 3)
$110 copay
$110 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$40 copay
$40 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Deductible (Individual)
$4,300
$4,300
Maximum Out-of-Pocket (Individual)
$8,150
$8,150
Deductible (Family)
$8,600
$8,600
Maximum Out-of-Pocket (Family)
$16,300
$16,300
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$35 copay
$35 copay
Specialist Visit
$70 copay
$70 copay
Retail Health Clinic
$35 copay
$35 copay
Urgent Care
$70 copay
$70 copay
Emergency Room
$600 copay after deductible
$600 copay after deductible
Ambulance
$300 copay after deductible
$300 copay after deductible
Surgeon
$200 copay after deductible
$200 copay after deductible
Outpatient Facility
40% coinsurance after deductible
40% coinsurance after deductible
Inpatient Hospital Stay
40% coinsurance per admission after deductible
40% coinsurance per admission after deductible
Acupuncture
$70 copay
$70 copay
Generic Drugs (Tier 1)
$20 copay
$20 copay
Brand Name Preferred (Tier 2)
$60 copay
$60 copay
Brand Name Non-Preferred (Tier 3)
$110 copay
$110 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$40 copay
$40 copay
Covered Prescription Drugs (Formulary)
English
Tier
Silver 40/75/4700 Pro Plus
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Silver 40/75/4700 Pro Plus
Deductible (Individual)
$4,700
$4,700
Maximum Out-of-Pocket (Individual)
$7,900
$7,900
Deductible (Family)
$9,400
$9,400
Maximum Out-of-Pocket (Family)
$15,800
$15,800
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$40 copay
$40 copay
Specialist Visit
$75 copay
$75 copay
Retail Health Clinic
$40 copay
$40 copay
Urgent Care
$75 copay
$75 copay
Emergency Room
$600 copay after deductible
$600 copay after deductible
Ambulance
$300 copay after deductible
$300 copay after deductible
Surgeon
$200 copay after deductible
$200 copay after deductible
Outpatient Facility
45% coinsurance after deductible
45% coinsurance after deductible
Inpatient Hospital Stay
45% coinsurance per admission after deductible
45% coinsurance per admission after deductible
Acupuncture
$75 copay
$75 copay
Generic Drugs (Tier 1)
$20 copay
$20 copay
Brand Name Preferred (Tier 2)
$60 copay
$60 copay
Brand Name Non-Preferred (Tier 3)
$110 copay
$110 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$40 copay
$40 copay
Covered Prescription Drugs (Formulary)
English
Tier
Silver 40/75/4700 Pro Plus
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copay
$0 copay
Silver 40/75/4700 Pro Plus
Deductible (Individual)
$4,700
$4,700
Maximum Out-of-Pocket (Individual)
$7,900
$7,900
Deductible (Family)
$9,400
$9,400
Maximum Out-of-Pocket (Family)
$15,800
$15,800
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
$40 copay
$40 copay
Specialist Visit
$75 copay
$75 copay
Retail Health Clinic
$40 copay
$40 copay
Urgent Care
$75 copay
$75 copay
Emergency Room
$600 copay after deductible
$600 copay after deductible
Ambulance
$300 copay after deductible
$300 copay after deductible
Surgeon
$200 copay after deductible
$200 copay after deductible
Outpatient Facility
45% coinsurance after deductible
45% coinsurance after deductible
Inpatient Hospital Stay
45% coinsurance per admission after deductible
45% coinsurance per admission after deductible
Acupuncture
$75 copay
$75 copay
Generic Drugs (Tier 1)
$20 copay
$20 copay
Brand Name Preferred (Tier 2)
$60 copay
$60 copay
Brand Name Non-Preferred (Tier 3)
$110 copay
$110 copay
90-Day Mail-Order Supply for Generic (Tier 1)
$40 copay
$40 copay
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
Other Eligibility Requirements
Small business with 1–100 employees
Dental Cleanings
Pediatric – 50% coinsurance after deductible
Adult – not covered
Pediatric – 50% coinsurance after deductible
Adult – 50% coinsurance after deductible
Vision Exams
Pediatric – $10 copay after deductible
Adult – not covered
Pediatric – $10 copay after deductible
Adult – $10 copay after deductible
Telemedicine (Teladoc )
$0 copy after deductible
$0 copy after deductible
Deductible (Individual)
$5,950
$5,950
Maximum Out-of-Pocket (Individual)
$6,900
$6,900
Deductible (Family)
$11,900
$11,900
Maximum Out-of-Pocket (Family)
$13,800
$13,800
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
50% coinsurance after deductible
50% coinsurance after deductible
Specialist Visit
50% coinsurance after deductible
50% coinsurance after deductible
Retail Health Clinic
50% coinsurance after deductible
50% coinsurance after deductible
Urgent Care
50% coinsurance after deductible
50% coinsurance after deductible
Emergency Room
50% coinsurance after deductible
50% coinsurance after deductible
Ambulance
50% coinsurance after deductible
50% coinsurance after deductible
Surgeon
50% coinsurance after deductible
50% coinsurance after deductible
Outpatient Facility
50% coinsurance after deductible
50% coinsurance after deductible
Inpatient Hospital Stay
50% coinsurance per admission after deductible
50% coinsurance per admission after deductible
Acupuncture
50% coinsurance after deductible
50% coinsurance after deductible
Generic Drugs (Tier 1)
50% coinsurance after deductible
50% coinsurance after deductible
Brand Name Preferred (Tier 2)
50% coinsurance after deductible
50% coinsurance after deductible
Brand Name Non-Preferred (Tier 3)
50% coinsurance after deductible
50% coinsurance after deductible
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
Other Eligibility Requirements
Small business with 1–100 employees
Dental Cleanings
Pediatric – 50% coinsurance after deductible
Adult – not covered
Pediatric – 50% coinsurance after deductible
Adult – 50% coinsurance after deductible
Vision Exams
Pediatric – $10 copay after deductible
Adult – not covered
Pediatric – $10 copay after deductible
Adult – $10 copay after deductible
Telemedicine (Teladoc )
$0 copy after deductible
$0 copy after deductible
Deductible (Individual)
$5,950
$5,950
Maximum Out-of-Pocket (Individual)
$6,900
$6,900
Deductible (Family)
$11,900
$11,900
Maximum Out-of-Pocket (Family)
$13,800
$13,800
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
50% coinsurance after deductible
50% coinsurance after deductible
Specialist Visit
50% coinsurance after deductible
50% coinsurance after deductible
Retail Health Clinic
50% coinsurance after deductible
50% coinsurance after deductible
Urgent Care
50% coinsurance after deductible
50% coinsurance after deductible
Emergency Room
50% coinsurance after deductible
50% coinsurance after deductible
Ambulance
50% coinsurance after deductible
50% coinsurance after deductible
Surgeon
50% coinsurance after deductible
50% coinsurance after deductible
Outpatient Facility
50% coinsurance after deductible
50% coinsurance after deductible
Inpatient Hospital Stay
50% coinsurance per admission after deductible
50% coinsurance per admission after deductible
Acupuncture
50% coinsurance after deductible
50% coinsurance after deductible
Generic Drugs (Tier 1)
50% coinsurance after deductible
50% coinsurance after deductible
Brand Name Preferred (Tier 2)
50% coinsurance after deductible
50% coinsurance after deductible
Brand Name Non-Preferred (Tier 3)
50% coinsurance after deductible
50% coinsurance after deductible
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copy after deductible
$0 copy after deductible
Deductible (Individual)
$6,850
$6,850
Maximum Out-of-Pocket (Individual)
$6,850
$6,850
Deductible (Family)
$13,700
$13,700
Maximum Out-of-Pocket (Family)
$13,700
$13,700
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
0% coinsurance after deductible
0% coinsurance after deductible
Specialist Visit
0% coinsurance after deductible
0% coinsurance after deductible
Retail Health Clinic
0% coinsurance after deductible
0% coinsurance after deductible
Urgent Care
0% coinsurance after deductible
0% coinsurance after deductible
Emergency Room
0% coinsurance after deductible
0% coinsurance after deductible
Ambulance
0% coinsurance after deductible
0% coinsurance after deductible
Surgeon
0% coinsurance after deductible
0% coinsurance after deductible
Outpatient Facility
0% coinsurance after deductible
0% coinsurance after deductible
Inpatient Hospital Stay
0% coinsurance per admission after deductible
0% coinsurance per admission after deductible
Acupuncture
0% coinsurance after deductible
0% coinsurance after deductible
Generic Drugs (Tier 1)
0% coinsurance after deductible
0% coinsurance after deductible
Brand Name Preferred (Tier 2)
0% coinsurance after deductible
0% coinsurance after deductible
Brand Name Non-Preferred (Tier 3)
0% coinsurance after deductible
0% coinsurance after deductible
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
English
More Languages
English
More Languages
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Long Island
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
Telemedicine (Teladoc )
$0 copy after deductible
$0 copy after deductible
Deductible (Individual)
$6,850
$6,850
Maximum Out-of-Pocket (Individual)
$6,850
$6,850
Deductible (Family)
$13,700
$13,700
Maximum Out-of-Pocket (Family)
$13,700
$13,700
Your Annual Checkup (Preventive Care )
$0 copay
$0 copay
Primary Care Provider (PCP) Visit
0% coinsurance after deductible
0% coinsurance after deductible
Specialist Visit
0% coinsurance after deductible
0% coinsurance after deductible
Retail Health Clinic
0% coinsurance after deductible
0% coinsurance after deductible
Urgent Care
0% coinsurance after deductible
0% coinsurance after deductible
Emergency Room
0% coinsurance after deductible
0% coinsurance after deductible
Ambulance
0% coinsurance after deductible
0% coinsurance after deductible
Surgeon
0% coinsurance after deductible
0% coinsurance after deductible
Outpatient Facility
0% coinsurance after deductible
0% coinsurance after deductible
Inpatient Hospital Stay
0% coinsurance per admission after deductible
0% coinsurance per admission after deductible
Acupuncture
0% coinsurance after deductible
0% coinsurance after deductible
Generic Drugs (Tier 1)
0% coinsurance after deductible
0% coinsurance after deductible
Brand Name Preferred (Tier 2)
0% coinsurance after deductible
0% coinsurance after deductible
Brand Name Non-Preferred (Tier 3)
0% coinsurance after deductible
0% coinsurance after deductible
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island) and Long Island.
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
Telemedicine (Teladoc )
0% coinsurance after deductible
Deductible (Individual)
$8,150
Maximum Out-of-Pocket (Individual)
$8,150
Deductible (Family)
$16,300
Maximum Out-of-Pocket (Family)
$16,300
Your Annual Checkup (Preventive Care )
$0 copay
Primary Care Provider (PCP) Visit
0% coinsurance after deductible
Specialist Visit
0% coinsurance after deductible
Retail Health Clinic
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
Outpatient Facility
0% coinsurance after deductible
Inpatient Hospital Stay
0% coinsurance after deductible
Acupuncture
0% coinsurance after deductible
Generic Drugs (Tier 1)
0% coinsurance after deductible
Brand Name Preferred (Tier 2)
0% coinsurance after deductible
Brand Name Non-Preferred (Tier 3)
0% coinsurance after deductible
Covered Prescription Drugs (Formulary)
English
Summary of Benefits and Coverage (PDF)
Eligible Service Areas
Within New York City's five boroughs (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island) and Long Island.
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
Telemedicine (Teladoc )
0% coinsurance after deductible
Deductible (Individual)
$8,150
Maximum Out-of-Pocket (Individual)
$8,150
Deductible (Family)
$16,300
Maximum Out-of-Pocket (Family)
$16,300
Your Annual Checkup (Preventive Care )
$0 copay
Primary Care Provider (PCP) Visit
0% coinsurance after deductible
Specialist Visit
0% coinsurance after deductible
Retail Health Clinic
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
Outpatient Facility
0% coinsurance after deductible
Inpatient Hospital Stay
0% coinsurance after deductible
Acupuncture
0% coinsurance after deductible
Generic Drugs (Tier 1)
0% coinsurance after deductible
Brand Name Preferred (Tier 2)
0% coinsurance after deductible
Brand Name Non-Preferred (Tier 3)
0% coinsurance after deductible
Covered Prescription Drugs (Formulary)
English
* 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.
* Telemedicine isn’t a replacement for your Primary Care Provider (PCP). Your PCP should always be your first choice for care (both in-person and virtual visits).
Active & Fit Direct
Healthfirst makes working out affordable too! For just $25/month, you get a standard membership to a fitness center in your area. Premium fitness center options are available for an additional fee. Track your activity, monitor your progress, achieve your fitness goals, and so much more! Visit activeandfitdirect.com to learn more.
ExerciseRewards™ Program
Physical activity is one of the simplest ways to stay healthy, and Healthfirst makes it even more rewarding! With the Active&Fit ExerciseRewards™ program, you can earn $200 every six months if you visit a qualifying fitness center at least 50 days during the same six-month reward period. Contact ExerciseRewards at 1-877-810-2746 to learn more about qualifying fitness centers.
Additional Benefits
24/7 Access to Telemedicine with Teladoc*
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.
* Telemedicine isn’t a replacement for your Primary Care Provider (PCP). Your PCP should always be your first choice for care (both in-person and virtual visits).
Active & Fit Direct Healthfirst makes working out affordable too! For just $25/month, you get a standard membership to a fitness center in your area. Premium fitness center options are available for an additional fee. Track your activity, monitor your progress, achieve your fitness goals, and so much more! Visit activeandfitdirect.com to learn more.
ExerciseRewards™ Program Physical activity is one of the simplest ways to stay healthy, and Healthfirst makes it even more rewarding! With the Active&Fit ExerciseRewards™ program, you can earn $200 every six months if you visit a qualifying fitness center at least 50 days during the same six-month reward period. Contact ExerciseRewards at 1-877-810-2746 to learn more about qualifying fitness centers.
What will my plan cover?
Healthfirst offers a wide variety of plans with different benefit packages to cover all your healthcare needs, but all Healthfirst plans cover most medically necessary and preventive services. These are called “Essential Health Benefits” and include:
Doctor visits
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance abuse disorder services
Prescription drugs
Rehabilitative and habilitative service and devices
Lab and imaging services
Wellness visits and checkups
Children’s health, including vision and dental services
Is my doctor part of the network?
Healthfirst has a large network that includes thousands of doctors and specialists. Visit HFDocFinder to find an in-network Healthfirst provider.
When will I receive my ID card?
For any plan with a premium, your Member ID card will be mailed after the initial payment (known as a binder payment) has been made
For any plan without a premium, your Member ID card will be mailed upon enrollment
You can also print a temporary Member ID card from your secure Healthfirst account
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Links to non-Healthfirst websites are provided for your convenience only. Healthfirst is not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
We have updated our Terms of Use and Website Privacy Policy, effective October 15th, 2020.You can review the updated Terms of Use here and Website Privacy Policy here .
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