MVP Premier Plus Silver 3 HDHP, Silver, NS, INN, NY Individual On Exchange HMO, Dep29, Acupuncture, HSA, Preferred Facilities, Preventive Rx, Telemedicine, Wellness

Health Insurance Plan Details (2024 Plan)

by MVP Health Care

Monthly Premium

HMO
$ubsidy
HSA
Silver
Deductible
$2,650 /yr
Max Out-of-Pocket
$6,200 /yr

Details

Deductible (per individual) $2,650 /yr
Deductible (per family) $5,300 /yr
Max Out-of-Pocket (per individual) $6,200 /yr
Max Out-of-Pocket (per family) $12,400 /yr
Drug Deductible (per individual)
Drug Deductible (per family)
Drug Max Out-of-Pocket (per individual)
Drug Max Out-of-Pocket (per family)
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $30 Copay after deductible
Specialist Visit $60 Copay after deductible
Emergency Room $325 Copay after deductible
Inpatient Facility $500 Copay per Stay after deductible
Inpatient Physician $100 Copay after deductible
Drug Costs
Generic Drugs $10 Copay after deductible
Preferred Brand Drugs $45 Copay after deductible
Non-preferred Brand Drugs $90 Copay after deductible
Specialty Drugs $90 Copay after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List n/a

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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