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Zip Code	11226 (edit)
Applicant	2/17/1984 Male (edit)
Coverage Start	2/18/2019 (edit)

Insurance Type	ACA (Obamacare)
Plan Name	MVP Premier Plus Bronze 2 NS INN Dep29 Acupuncture Telemedicine
Plan ID	hhs-56184NY0150008
Plan Year	2018
Insurance Provider	MVP
Metal Level	Expanded Bronze
Plan Type	HMO
Deductible	$5,100
Out-of-Pocket Maximum	$7,150
Personal Score
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	40.00% Coinsurance after deductible
Specialist Visit	40.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	40.00% Coinsurance after deductible
X-rays and Diagnostic Imaging	40.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	40.00% Coinsurance after deductible
Deductible - Family	$10200 per group
Out-of-Pocket Maximum - Family	$14300 per group

Prescription drug coverage
Generic Drugs	$5 Copay after deductible
Preferred Brand Drugs	$60 Copay after deductible
Non-Preferred Brand Drugs	$80 Copay after deductible
Specialty Drugs	Not Applicable

Access to doctors and hospitals
Provider directory URL	https://www.mvphealthcare.com/members/find-a-doctor/
Does this plan have access to a national provider network?	No
Is a referral required to see a Specialist?	Not Covered
Does this plan cover services outside plan service area?	Yes - Emergency Only
Does this plan cover services outside the country?	Yes - Emergency Only

Hospital services
Emergency Room Services	40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	40.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	40.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service	40.00% Coinsurance after deductible

Maternity
Prenatal and Postnatal Care	Not Applicable
Delivery and all inpatient services for maternity care	40.00% Coinsurance after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	40.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services	40.00% Coinsurance after deductible
Substance use disorder outpatient services	40.00% Coinsurance after deductible
Substance use disorder inpatient services	40.00% Coinsurance after deductible

Medical Management Programs
Does this plan offer disease managment programs?	Asthma, Depression, Diabetes, Heart Disease, Low Back Pain, Pregnancy
Does this plan offer a wellness program?	Not Covered

Vision Coverage
Routine Eye Exam for Children	Included
Eye Glasses for Children	Included
Routine Eye Exam for Adults	Not Covered

Child Dental Coverage
Child Dental Coverage - Routine Dental Care	Not Covered
Child Dental Coverage - Basic Dental Care	Not Covered
Child Dental Coverage - Orthodontia	Not Covered
Child Dental Coverage - Major Dental Care	Not Covered

Adult Dental Coverage
Adult Dental Coverage - Routine Dental Care	Not Covered
Adult Dental Coverage - Basic Dental Care	Not Covered
Adult Dental Coverage - Orthodontia	Not Covered
Adult Dental Coverage - Major Dental Care	Not Covered

Exclusions and Limitations
More Included Benefits	Other Practitioner Office Visit (Nurse, Physician Assistant) Preventive Care/Screening/Immunization Bariatric Surgery Infertility Treatment Imaging (CT/PET Scans, MRIs) Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services Urgent Care Centers or Facilities Inpatient Physician and Surgical Services Durable Medical Equipment Chiropractic Care Applied Behavior Analysis Based Therapies Cochlear Implants Second Opinion Accidental Dental Allergy Testing Chemotherapy Diabetes Education Dialysis Infusion Therapy Laboratory Outpatient and Professional Services Prosthetic Devices Radiation Reconstructive Surgery Transplant Treatment for Temporomandibular Joint Disorders Well Baby Visits and Care Breast Reconstructive Surgery Cardiac Rehabilitation Prostate Cancer Screening Assistive Communication Devices Autologous Blood Banking Gym Membership Reimbursement Medical Supplies Preadmission Testing Design Diabetic Equipment and Supplies Family Planning Services Sterilization Procedures for Men Telemedicine
More Limited Benefits	Skilled Nursing Facility Acupuncture Hearing Aids Home Health Care Services Outpatient Rehabilitation Services Habilitation Services Hospice Services Inpatient Rehabilitation Services Abortion for Which Public Funding is Prohibited Rehabilitative Occupational and Rehabilitative Physical Therapy Rehabilitative Speech Therapy Contact Lenses for Children
More Excluded Benefits	Cosmetic Surgery Long-Term/Custodial Nursing Home Care Private-Duty Nursing Weight Loss Programs Dental Check-Up for Children Routine Foot Care Nutritional Counseling

+ See All Coverage Details

Premium

Plan Name

Deductible

from $346

MVP Premier Plus Bronze 2, NS, INN, Dep25, Acupuncture, Preferr

$5,100.00

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from $385

Bronze Select NS INN Dep29

$5,000.00

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from $386

Bronze Select NS INN Pediatric Dental Dep29

$5,000.00

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from $398

iDirect Bronze HSAQ NS OON Dep25 Adult Vision Wellness Nurse He

$5,000.00

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from $402

iDirect Bronze HSAQ NS OON Dep29 Adult Vision Wellness Nurse He

$5,000.00

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Location/Distance

Please select the correct zip

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View All Details

Phone Number
(718) 434-7545
Office Locations
29 Newkirk Plz
Brooklyn, NY 11226

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MVP Premier Plus Bronze 2 NS INN Dep29 Acupuncture Telemedicine

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Prescription drug coverage

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