HEALTHFIRST PHSP, INC. Rate Manual Pursuant to New York … · 2019. 9. 11. · Healthfirst Bronze Leaf 91237NY0020003 Standard, Age 26 $466.16 $932.32 $792.47 $1,328.56 Healthfirst

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HEALTHFIRST PHSP, INC.

Rate Manual Pursuant to New York Insurance Law Section 4308(c)

Individual HMO Rates and Forms Submission

Effective January 1, 2020

_____________________________________________________________________________________ Healthfirst PHSP, Inc. 2020 Rate Manual; Individual Market Page 2 of 31

TABLE OF CONTENTS

I. On-Exchange Individual Plan Rates………………………………………………………………………………… 3 A. New York City rating region (#4) rates…………………………………………………….……….……... 4

B. Long Island rating region (#8) rates………………….…………………………….……….……………... 7

II. Off-Exchange Individual Plan Rates………………………………………………………………………………… 10 A. New York City rating region (#4) rates…..……………………………………….………………………... 11

B. Long Island rating region (#8) rates………………….…………………………….………...……………....14

III. Rating Factors, Rate Calculations, Loss Ratios, and Commissions/Fees………………………….17

IV. Description of Benefits, Types of Coverage, Limitations, & Exclusions…………………………..22

A. Healthfirst Standard Benefit Descriptions (On & Off Exchange)………………….…..………... 23

B. Healthfirst Non-Standard Plans Benefit Descriptions (On & Off Exchange)...…………….. 26


SECTION I

On-Exchange Individual HMO Plan Rates

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Section I.A – Rate Pages: On-Exchange Standard & Non-Standard Plans – New York City Rating Region

HEALTHFIRST PHSP, INC. ON-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS

RATE PAGES - EFFECTIVE JANUARY 1, 2020 AREA: New York City Rating Region (NEW YORK, KINGS, QUEENS, RICHMOND, & BRONX COUNTIES) – Rating Region #4

Platinum

Applicable Form Numbers: HF-STDIND-20, HF-STDCO-20, HF-PSOB-20, HF-NoCSSOB-20 Premium Per Month

Product HIOS ID Product Description Single Single + Spouse

Single + Child(ren)

Single + Spouse + Child(ren)

Healthfirst Platinum Leaf 91237NY0020015 Standard, Age 26 $947.45 $1,894.90 $1,610.67 $2,700.23

Healthfirst Platinum Leaf, Age 29 Rider 91237NY0020016 Standard, Age 29 $956.92 $1,913.84 $1,626.76 $2,727.22

Healthfirst Platinum Leaf Premier 91237NY0020058 Non-Standard, Age 26 $980.43 $1,960.86 $1,666.73 $2,794.23

Healthfirst Platinum Leaf Premier, Age 29 Rider 91237NY0020059 Non-Standard, Age 29 $990.22 $1,980.44 $1,683.37 $2,822.13

One Child Two Children

Three or More

Healthfirst Platinum Leaf Child-Only 91237NY0020026 Child-Only $390.36 $780.72 $1,171.08

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Gold

Applicable Form Numbers: HF-STDIND-20, HF-GSOB-20, HF-GSOBNS-20, HF-NoCSSOB-20 Premium Per Month


Single + Child(ren)


Healthfirst Gold Leaf 91237NY0020011 Standard, Age 26 $752.21 $1,504.42 $1,278.76 $2,143.80

Healthfirst Gold Leaf, Age 29 Rider 91237NY0020012 Standard, Age 29 $759.71 $1,519.42 $1,291.51 $2,165.17

Healthfirst Gold Leaf Premier 91237NY0020056 Non-Standard, Age 26 $785.77 $1,571.54 $1,335.81 $2,239.44

Healthfirst Gold Leaf Premier, Age 29 Rider 91237NY0020057 Non-Standard, Age 29 $793.63 $1,587.26 $1,349.17 $2,261.85

One Child Two Children Three or More

Healthfirst Gold Leaf Child-Only 91237NY0020024 Child-Only $309.90 $619.80 $929.70

Silver

Applicable Form Numbers: HF-STDIND-20, HF-STDCO-20, HF-SSOB-20, HF-SSOBNS-20, HF-S200SOB-20, HF-S200SOBNS-20, HF-S150SOB-20, HF-S100SOB-20, HF-NoCSSOB-20 Premium Per Month


Single + Child(ren)


Healthfirst Silver Leaf 91237NY0020007 Standard, Age 26 $622.90 $1,245.80 $1,058.93 $1,775.27

Healthfirst Silver Leaf, Age 29 Rider 91237NY0020008 Standard, Age 29 $629.13 $1,258.26 $1,069.52 $1,793.02

Healthfirst Silver Leaf Premier 91237NY0020054 Non-Standard, Age 26 $648.91 $1,297.82 $1,103.15 $1,849.39

Healthfirst Silver Leaf Premier, Age 29 Rider 91237NY0020055 Non-Standard, Age 29 $655.40 $1,310.80 $1,114.18 $1,867.89


Healthfirst Silver Leaf Child-Only 91237NY0020022 Child-Only $256.65 $513.30 $769.95


Bronze

Applicable Form Numbers: HF-STDIND-20, HF-STDCO-20, HF-BSOB-20, HF-NoCSSOB-20 Premium Per Month


Single + Child(ren)


Healthfirst Bronze Leaf 91237NY0020003 Standard, Age 26 $466.16 $932.32 $792.47 $1,328.56

Healthfirst Bronze Leaf, Age 29 Rider 91237NY0020004 Standard, Age 29 $470.82 $941.64 $800.39 $1,341.84

Healthfirst Bronze Leaf Premier 91237NY0020052 Non-Standard, Age 26 $482.38 $964.76 $820.05 $1,374.78

Healthfirst Bronze Leaf Premier, Age 29 Rider 91237NY0020053 Non-Standard, Age 29 $487.20 $974.40 $828.24 $1,388.52


Three or More

Healthfirst Bronze Leaf Child-Only 91237NY0020020 Child-Only $192.05 $384.10 $576.15 Catastrophic

Applicable Form Numbers: HF-STDCC-20, HF-CCSOB-20, HF-NoCSSOB-20 Premium Per Month


Single + Child(ren)


Healthfirst Green Leaf 91237NY0020018 Standard, Age 26 $287.57 $575.14 $488.87 $819.57


Section I.B – Rate Pages: On-Exchange Standard & Non-Standard Plans – Long Island Rating Region

HEALTHFIRST PHSP, INC. ON-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS

RATE PAGES - EFFECTIVE JANUARY 1, 2020 AREA: Long Island Rating Region (NASSAU & SUFFOLK COUNTIES) – Rating Region #8

Platinum

Applicable Form Numbers: HF-STDIND-20, HF-STDCO-20, HF-PSOB-20, HF-NoCSSOB-20 Premium Per Month


Single + Child(ren)


Healthfirst Platinum Leaf 91237NY0020015 Standard, Age 26 $975.70 $1,951.40 $1,658.69 $2,780.75

Healthfirst Platinum Leaf, Age 29 Rider 91237NY0020016 Standard, Age 29 $985.46 $1,970.92 $1,675.28 $2,808.56

Healthfirst Platinum Leaf Premier 91237NY0020058 Non-Standard, Age 26 $1,009.67 $2,019.34 $1,716.44 $2,877.56

Healthfirst Platinum Leaf Premier, Age 29 Rider 91237NY0020059 Non-Standard, Age 29 $1,019.76 $2,039.52 $1,733.59 $2,906.32


Three or More

Healthfirst Platinum Leaf Child-Only 91237NY0020026 Child-Only $401.99 $803.98 $1,205.97


Gold

Applicable Form Numbers: HF-STDIND-20, HF-GSOB-20, HF-GSOBNS-20, HF-NoCSSOB-20 Premium Per Month


Single + Child(ren)


Healthfirst Gold Leaf 91237NY0020011 Standard, Age 26 $775.17 $1,550.34 $1,317.79 $2,209.23

Healthfirst Gold Leaf, Age 29 Rider 91237NY0020012 Standard, Age 29 $782.90 $1,565.80 $1,330.93 $2,231.27

Healthfirst Gold Leaf Premier 91237NY0020056 Non-Standard, Age 26 $809.78 $1,619.56 $1,376.63 $2,307.87

Healthfirst Gold Leaf Premier, Age 29 Rider 91237NY0020057 Non-Standard, Age 29 $817.87 $1,635.74 $1,390.38 $2,330.93


Three or More

Healthfirst Gold Leaf Child-Only 91237NY0020024 Child-Only $319.37 $638.74 $958.11

Silver

Applicable Form Numbers: HF-STDIND-20, HF-STDCO-20, HF-SSOB-20, HF-SSOBNS-20, HF-S200SOB-20, HF-S200SOBNS-20, HF-S150SOB-20, HF-S100SOB-20, HF-NoCSSOB-20 Premium Per Month


Single + Child(ren)


Healthfirst Silver Leaf 91237NY0020007 Standard, Age 26 $641.72 $1,283.44 $1,090.92 $1,828.90

Healthfirst Silver Leaf, Age 29 Rider 91237NY0020008 Standard, Age 29 $648.14 $1,296.28 $1,101.84 $1,847.20

Healthfirst Silver Leaf Premier 91237NY0020054 Non-Standard, Age 26 $668.52 $1,337.04 $1,136.48 $1,905.28

Healthfirst Silver Leaf Premier, Age 29 Rider 91237NY0020055 Non-Standard, Age 29 $675.22 $1,350.44 $1,147.87 $1,924.38


Healthfirst Silver Leaf Child-Only 91237NY0020022 Child-Only $264.40 $528.80 $793.20


Bronze

Applicable Form Numbers: HF-STDIND-20, HF-STDCO-20, HF-BSOB-20, HF-NoCSSOB-20 Premium Per Month


Single + Child(ren)


Healthfirst Bronze Leaf 91237NY0020003 Standard, Age 26 $480.11 $960.22 $816.19 $1,368.31

Healthfirst Bronze Leaf, Age 29 Rider 91237NY0020004 Standard, Age 29 $484.89 $969.78 $824.31 $1,381.94

Healthfirst Bronze Leaf Premier 91237NY0020052 Non-Standard, Age 26 $496.80 $993.60 $844.56 $1,415.88

Healthfirst Bronze Leaf Premier, Age 29 Rider 91237NY0020053 Non-Standard, Age 29 $501.78 $1,003.56 $853.03 $1,430.07


Three or More

Healthfirst Bronze Leaf Child-Only 91237NY0020020 Child-Only $197.80 $395.60 $593.40

Catastrophic

Applicable Form Numbers: HF-STDCC-20, HF-CCSOB-20, HF-NoCSSOB-20 Premium Per Month


Single + Child(ren)


Healthfirst Green Leaf 91237NY0020018 Standard, Age 26 $296.17 $592.34 $503.49 $844.08


SECTION II

Off-Exchange Individual HMO Plan Rates

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Section II.A – Rate Pages: Off-Exchange Standard Plans – New York City Rating Region

HEALTHFIRST PHSP, INC. OFF-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS

RATE PAGES - EFFECTIVE JANUARY 1, 2020 AREA: New York City Rating Region (NEW YORK, KINGS, QUEENS, RICHMOND, & BRONX COUNTIES) - Rating Region #4

Platinum

Applicable Form Numbers: HF-STDIND-20-OFF, HF-PSOB-20-OFF Premium Per Month


Single + Child(ren)


Healthfirst HMO A 91237NY0020039 Standard, Age 26 $947.45 $1,894.90 $1,610.67 $2,700.23

Healthfirst HMO A, Age 29 Rider 91237NY0020040 Standard, Age 29 $956.92 $1,913.84 $1,626.76 $2,727.22

Healthfirst HMO A-VAD 91237NY0020067 Non-Standard, Age 26 $980.43 $1,960.86 $1,666.73 $2,794.23

Healthfirst HMO A-VAD, Age 29 Rider 91237NY0020068 Non-Standard, Age 29 $990.22 $1,980.44 $1,683.37 $2,822.13


Three or More

Healthfirst HMO A Child-Only 91237NY0020049 Child-Only $390.36 $780.72 $1,171.08

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Gold Applicable Form Numbers: HF-STDIND-20-OFF, HF-GSOB-20-OFF Premium Per Month


Single + Child(ren)


Healthfirst HMO B 91237NY0020035 Standard, Age 26 $752.21 $1,504.42 $1,278.76 $2,143.80

Healthfirst HMO B, Age 29 Rider 91237NY0020036 Standard, Age 29 $759.71 $1,519.42 $1,291.51 $2,165.17

Healthfirst HMO B-VAD 91237NY0020065 Non-Standard, Age 26 $785.77 $1,571.54 $1,335.81 $2,239.44

Healthfirst HMO B-VAD, Age 29 Rider 91237NY0020066 Non-Standard, Age 29 $793.63 $1,587.26 $1,349.17 $2,261.85


Three or More

Healthfirst HMO B Child-Only 91237NY0020047 Child-Only $309.90 $619.80 $929.70

Silver Applicable Form Numbers: HF-STDIND-20-OFF, HF-SSOB-20-OFF Premium Per Month


Single + Child(ren)


Healthfirst HMO C 91237NY0020031 Standard, Age 26 $622.90 $1,245.80 $1,058.93 $1,775.27 Healthfirst HMO C, Age 29 Rider 91237NY0020032 Standard, Age 29 $629.13 $1,258.26 $1,069.52 $1,793.02

Healthfirst HMO C-VAD 91237NY0020063 Non-Standard, Age 26 $648.91 $1,297.82 $1,103.15 $1,849.39

Healthfirst HMO C-VAD, Age 29 Rider 91237NY0020064 Non-Standard, Age 29 $655.40 $1,310.80 $1,114.18 $1,867.89


Three or More

Healthfirst HMO C Child-Only 91237NY0020045 Child-Only $256.65 $513.30 $769.95


Bronze Applicable Form Numbers: HF-STDIND-20-OFF, HF-BSOB-20-OFF Premium Per Month


Single + Child(ren)


Healthfirst HMO D 91237NY0020027 Standard, Age 26 $466.16 $932.32 $792.47 $1,328.56

Healthfirst HMO D, Age 29 Rider 91237NY0020028 Standard, Age 29 $470.82 $941.64 $800.39 $1,341.84

Healthfirst HMO D-VAD 91237NY0020061 Non-Standard, Age 26 $482.38 $964.76 $820.05 $1,374.78

Healthfirst HMO D-VAD, Age 29 Rider 91237NY0020062 Non-Standard, Age 29 $487.20 $974.40 $828.24 $1,388.52


Three or More

Healthfirst HMO D Child-Only 91237NY0020043 Child-Only $192.05 $384.10 $576.15

Catastrophic

Applicable Form Numbers: HF-STDCC-20-OFF, HF-CCSOB-20-OFF Premium Per Month


Single + Child(ren)


Healthfirst HMO E 91237NY0020069 Standard, Age 26 $287.57 $575.14 $488.87 $819.57


Section II.B – Rate Pages: Off-Exchange Standard & Non-Standard Plans – Long Island Rating Region

HEALTHFIRST PHSP, INC. OFF-EXCHANGE INDIVIDUAL HMO STANDARD & NON-STANDARD PLANS

RATE PAGES - EFFECTIVE JANUARY 1, 2020 AREA: Long Island Rating Region (NASSAU & SUFFOLK COUNTIES) - Rating Region #8

Platinum

Applicable Form Numbers: HF-STDIND-20-OFF, HF-PSOB-20-OFF Premium Per Month


Single + Child(ren)


Healthfirst HMO A 91237NY0020039 Standard, Age 26 $975.70 $1,951.40 $1,658.69 $2,780.75

Healthfirst HMO A, Age 29 Rider 91237NY0020040 Standard, Age 29 $985.46 $1,970.92 $1,675.28 $2,808.56

Healthfirst HMO A-VAD 91237NY0020067 Non-Standard, Age 26 $1,009.67 $2,019.34 $1,716.44 $2,877.56

Healthfirst HMO A-VAD, Age 29 Rider 91237NY0020068 Non-Standard, Age 29 $1,019.76 $2,039.52 $1,733.59 $2,906.32


Three or More

Healthfirst HMO A Child-Only 91237NY0020049 Child-Only $401.99 $803.98 $1,205.97


Gold Applicable Form Numbers: HF-STDIND-20-OFF, HF-GSOB-20-OFF Premium Per Month


Single + Child(ren)


Healthfirst HMO B 91237NY0020035 Standard, Age 26 $775.17 $1,550.34 $1,317.79 $2,209.23

Healthfirst HMO B, Age 29 Rider 91237NY0020036 Standard, Age 29 $782.90 $1,565.80 $1,330.93 $2,231.27

Healthfirst HMO B-VAD 91237NY0020065 Non-Standard, Age 26 $809.78 $1,619.56 $1,376.63 $2,307.87

Healthfirst HMO B-VAD, Age 29 Rider 91237NY0020066 Non-Standard, Age 29 $817.87 $1,635.74 $1,390.38 $2,330.93


Three or More

Healthfirst HMO B Child-Only 91237NY0020047 Child-Only $319.37 $638.74 $958.11

Silver

Applicable Form Numbers: HF-STDIND-20-OFF, HF-SSOB-20-OFF Premium Per Month


Single + Child(ren)


Healthfirst HMO C 91237NY0020031 Standard, Age 26 $641.72 $1,283.44 $1,090.92 $1,828.90 Healthfirst HMO C, Age 29 Rider 91237NY0020032 Standard, Age 29 $648.14 $1,296.28 $1,101.84 $1,847.20

Healthfirst HMO C-VAD 91237NY0020063 Non-Standard, Age 26 $668.52 $1,337.04 $1,136.48 $1,905.28

Healthfirst HMO C-VAD, Age 29 Rider 91237NY0020064 Non-Standard, Age 29 $675.22 $1,350.44 $1,147.87 $1,924.38


Three or More

Healthfirst HMO C Child-Only 91237NY0020045 Child-Only $264.40 $528.80 $793.20


Bronze Applicable Form Numbers: HF-STDIND-20-OFF, HF-BSOB-20-OFF Premium Per Month


Single + Child(ren)


Healthfirst HMO D 91237NY0020027 Standard, Age 26 $480.11 $960.22 $816.19 $1,368.31

Healthfirst HMO D, Age 29 Rider 91237NY0020028 Standard, Age 29 $484.89 $969.78 $824.31 $1,381.94

Healthfirst HMO D-VAD 91237NY0020061 Non-Standard, Age 26 $496.80 $993.60 $844.56 $1,415.88

Healthfirst HMO D-VAD, Age 29 Rider 91237NY0020062 Non-Standard, Age 29 $501.78 $1,003.56 $853.03 $1,430.07


Three or More

Healthfirst HMO D Child-Only 91237NY0020043 Child-Only $197.80 $395.60 $593.40

Catastrophic

Applicable Form Numbers: HF-STDCC-20-OFF, HF-CCSOB-20-OFF Premium Per Month


Single + Child(ren)


Healthfirst HMO E 91237NY0020069 Standard, Age 26 $296.17 $592.34 $503.49 $844.08

SECTION III

Rating Factors, Rate Calculations, Loss Ratios, & Commissions/Fees


Section III.A – Description of Rating Classes, Factors, & Premium Discounts

Census Tiers Cost Factor

Single 1.000

Single + Spouse 2.000

Single + Child(ren) 1.700

Single + Spouse + Child(ren) 2.850

Child Only 0.412

Rating Region Counties Included Area Factor

New York City Bronx, Kings, New York, Queens, Richmond 1.000

Long Island Nassau, Suffolk 1.031

Dependent Age Limit Cost Factor

26 1.000

29 1.010


Section III.B – Rate Calculation Example

Healthfirst premium rates are developed in accordance with New York’s community rating law, and without any discounts or surcharge factors. Healthfirst’s plans are offered in Rating Regions 4 (NYC) & 8 (Long Island).

EXAMPLE: Consumer Profile:

• Census Tier: A single, individual subscriber • Residence: Kings County (New York City Rating Region) • Plan: Healthfirst Gold Leaf Standard Plan, not choosing the Age 29 Rider.

Rate look-up solution:

One would proceed to page 5 and refer to the table listing Gold-level plans. Next, one would refer to the row labeled, “Healthfirst Gold Leaf” and cross-reference the row labeled, “Single.” The rate for this plan is $749.14 per month.


Section III.C – Expected Loss Ratios

The projected loss ratio using the Federal medical loss ratio (MLR) methodology is 84.9%. The expected loss ratio under New York State’s MLR methodology is 83.5%.


Section III.D – Broker/Agent Commissions & Fees

The products and plans listed herein do not include any consideration related to broker/agent commissions and/or fees. Brokers/agents who sell these products and plans, accordingly, will not be compensated by Healthfirst for such sale.


SECTION IV

Description of Benefits, Types of Coverage, Limitations, Exclusions, Issue Limits,

& Renewal Conditions

*Note: the standard benefit description grid applies to all standard individual on- and off-exchange plans.


Section III. A – Healthfirst Standard Plans Benefit Description (On & Off Exchange)




Section III. B – 2020 Non-Standard Plan Benefit Descriptions (On- and Off-Exchange)

Platinum Leaf Premier/HMO A VAD Gold Leaf Premier/HMO B VAD Individual Deductible $0 $900 Max Out of Pocket (Individual)

$2,000 $5,000

Primary Care Doctor Visit $10 copayment $20 copayment Specialist Doctor Visit $40 copayment $40 copayment after deductible Emergency Room (Cost sharing waived if admitted)

$100 copayment $175 copayment after deductible

Ambulatory Surgical Center Facility Fee


Lab Diagnostic Office: PCP -$10 copayment SPC -$40 copayment Outpatient Hospital Services: $40 copayment

Office: PCP - $20 copayment SPC -$40 copayment Outpatient Hospital Services: $40 copayment

Inpatient Hospital Services [and Birthing Center]

$500 copayment per admission $1,000 copayment after deductible per Admission

Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy)


Skilled Nursing Facility 200 days per plan year


Inpatient Habilitation Services (Physical, Speech & Occupational therapy)



Platinum Leaf Premier/HMO A VAD Gold Leaf Premier/HMO B VAD Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy)


Mental Health/Substance Abuse - Inpatient


Mental Health/Substance Abuse - Outpatient / Behavioral Health

$10 copayment $20 copayment

Retail Generic Drugs (Tier 1) $5 copayment $7 copayment Retail Preferred Drugs (Tier 2) $50 copayment $50 copayment Retail Non-Preferred Drugs (Tier 3) $85 copayment $100 copayment

Silver Leaf Premier/HMO C VAD Silver Leaf 200-250 Premier Individual Deductible $4,000 $2,500 Max Out of Pocket (Individual)

$7,900 $7,500

Primary Care Doctor Visit $30 copayment $30 copayment Specialist Doctor Visit $50 copayment after deductible $50 copayment after deductible Emergency Room (Cost sharing waived if admitted)

$250 copayment after deductible $250 copayment after deductible



Lab Diagnostic Office: PCP - $30 copayment SPC -$50 copayment Outpatient Hospital Services: $50 copayment

Office: PCP - $30 copayment SPC -$50 copayment Outpatient Hospital Services: $50 copayment


Silver Leaf Premier/HMO C VAD Silver Leaf 200-250 Premier


$1,500 copayment after deductible per admission










Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy)







$30 copayment $30 copayment

Retail Generic Drugs (Tier 1) $7 copayment $7 copayment Retail Preferred Drugs (Tier 2) $50 copayment $50 copayment Retail Non-Preferred Drugs (Tier 3) $100 copayment $100 copayment

Bronze Leaf Premier/HMO B VAD Native American CSR Premier (all Metal Levels)

Individual Deductible $4,300 $0 Max Out of Pocket (Individual)

$8,150 $0


Bronze Leaf Premier/HMO B VAD Native American CSR Premier

(all Metal Levels) Primary Care Doctor Visit $35 copayment Covered in full Specialist Doctor Visit 50% Coinsurance after deductible Covered in full Emergency Room (Cost sharing waived if admitted)

50% Coinsurance after deductible Covered in full



Lab Diagnostic 50% Coinsurance after deductible Covered in full






50% Coinsurance after deductible per Admission

Covered in full



Covered in full

Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy)


Covered in full



Covered in full


$35 copayment Covered in full

Retail Generic Drugs (Tier 1) $8 copayment after deductible Covered in full


Bronze Leaf Premier/HMO B VAD Native American CSR Premier

(all Metal Levels) Retail Preferred Drugs (Tier 2) $60 copayment after deductible Covered in full Retail Non-Preferred Drugs (Tier 3) $95 copayment after deductible Covered in full

HEALTHFIRST PHSP, INC. Rate Manual Pursuant to New York … · 2019. 9. 11. · Healthfirst Bronze Leaf 91237NY0020003 Standard, Age 26 $466.16 $932.32 $792.47 $1,328.56 Healthfirst

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