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Pro Plan Plus Plan Advantage Plan Comfort Plan Senior Affordable Plan
Deductibles | Co-payments | Yearly Limits | Prescriptions | Vision | Download Full Plan
Limit Changes for 2017: These benefits apply to in-network benefits. Additional restrictions may apply to these benefits if out-of-network providers are utilized, which is detailed in the 2017 Summary Plan Description. *Limits are adjusted by HHS each year  
Prescription Benefits
Generic $5 copay at pharmacy // $10 copay via mail order
Non-Preferred Brand $30 copay at pharmacy // $60 copay via mail order
Preferred Brand $60 copay at pharmacy// $120 copay via mail order
copay are for the first $1,000 in plan payments for prescriptions. Afterwards all prescriptions with a 50% copay.
Major Medical
In-network deductible (individual/family) $3,000/$7,500
Co-insurance 30% (the plan will pay 70% of the in-network rate)
Lifetime Maximum Unlimited
Office Visit Copay $40
Specialist Copay $50
Laboratory Copay $50
X-ray Copay $50
Other Diagnostic Testing (MRI, Cat Scan, etc.) Deductible & Co-insurance
There is a maximum of three (3) copays per doctor visit. (i.e. could have a copay for an office visit, lab work & x-ray in one visit)
Hospital Benefits

Hospital In-Patient

Deductible & Co-Insurance
Hospital Out-Patient Deductible & Co-insurance
Emergency Room $250
Urgent Care $250 co-pay
 
Surgical Benefits
Surgical In-Patient Deductible & Co-Insurance
Surgical Out-Patient Deductible & Co-Insurance
Mental Health Benefits
Mental/Nervous in-patient Deductible & co-insurance (30 days per calendar year)
Mental / Nervous out-patient $50/$0 dependent child (30 days per calendar year
Other
Well Care (up to 19-years old) No Charge
Routine Adult Care No Charge (1 annual physical per calendar year)
Chiropractic Care $50 / $0 dependent child
Home Health Care Deductible & Co-insurance (75 visits per calendar year)
Therapy Services In-Patient Deductible & Co-insurance (30 days per calendar year)
Therapy Services Out Patient $50 / $0 dependent child (30 days per calendar year)
Durable Medical Equipment Deductible & Co-insurance
   
Monthly Premium
Employee Only Call for pricing (212) 967-3002 ext. 219
Husband & Wife or Parent & Child Call for Pricing (212) 967-3002 ext. 219
Family Call for Pricing (212) 967-3002 ext. 219

In-network Well Visits Now Without Copay:

  • Annual Physical (including lab work associated with annual physical)
  • Colonoscopy
  • Immunizations (dependents under 19- years old)
  • Mammogram
  • Routine OGBYN
  • Well Child

Services Now Covered:

  • Annual Physical with an out-of-network physician (subject to deductible & co-insurance.
  • Birth Control ($0 co-pay for generic, $30 co-pay for preferred brand, $60 co-pay for non-preferred brand)
  • Flu Vaccine (any age)
  • Pneumonia vaccination (any age) every 5 years

Services Not Covered:

Download the summary of Benefits