NY State of Health Marketplace plan Bronze-B4, ST, INN, Pediatric Dental, Dep25, DP, FP Silver-S4, ST, INN, Pediatric Dental, Dep25, DP, FP Gold-G4, ST, INN, Pediatric Dental, Dep25, DP, FP Platinum-P4, ST, INN, Pediatric Dental, Dep25, DP, FP Individual Rate 1 st Quarter* $543.25 $625.33 $733.06 $856.22 Individual Rate 2 nd Quarter* $551.66 $635.01 $744.40 $869.47 Individual Rate 3 rd Quarter* $560.20 $644.84 $755.92 $882.92 Individual Rate 4 th Quarter* $568.87 $654.82 $767.62 $896.58 Deductible – Individual $4,425 $1,300 $600 $0 Deductible – Family $8,850 $2,600 $1,200 $0 MOOP – Individual $8,150 $7,900 $4,000 $2,000 MOOP – Family $16,300 $15,800 $8,000 $4,000 PCP 50% cost sharing $30 copay $25 copay $15 copay Specialist 50% cost sharing $50 copay $40 copay $35 copay Urgent Care 50% cost sharing $70 copay $60 copay $55 copay Adult Dental / Vision Not covered Not covered Not covered Not covered Prescription Drugs 30 Days $10/$35/$70 $10/$35/$70 $10/$35/$70 $10/$30/$60 Mail Order R x – 90 days $25/$87.50/$175 $25/$87.50/$175 $25/$87.50/$175 $25/$75/$150 Lab Work 50% cost sharing Diagnostics (x-ray & blood work) $50 per visit Diagnostics (x-ray & blood work) $40 per visit Diagnostics (x-ray & blood work) $35 per visit Imaging (MRI, PET, CT) $50 per visit Imaging (MRI, PET, CT) $40 per visit Imaging (MRI, PET, CT) $35 per visit Inpatient (ER/Hospital) 50% cost sharing $250/$1500 $150/$1000 $100/$500 Outpatient Surgery (Facility/Physician) 50% cost sharing $150 $100 $100 Exercise Facility Reimbursement $200 per 6 month period $200 per 6 month period $200 per 6 month period $200 per 6 month period Pediatric Dental 50% cost sharing $30 copay $25 copay $15 copay Pediatric Vision 50% cost sharing Eye Exam – $30 copay Glasses – 30% coinsurance Eye Exam – $25 copay Glasses – 20% coinsurance Eye Exam – $15 copay Glasses – 10% coinsurance Other Services Chiropractic & Hearing Aids (50%) Chiropractic ($50) & Hearing Aids (30%) Chiropractic ($40) & Hearing Aids (20%) Chiropractic ($35) & Hearing Aids (10%) SMALL BUSINESS HEALTH OPTIONS PROGRAM (SHOP) MetroPlus small business Plans at‑a‑glance 2020 *Multiply individual rate above by 2.00 for Employee + Spouse; by 1.70 for Employee + Child(ren); by 2.85 for Family MBR 19.227 See back for abbreviations/definitions. nystateofhealth.ny.gov 1.855.355.5777 TTY: 1.800.662.1220
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NY State of Health Marketplace plan
Bronze-B4, ST, INN, Pediatric Dental, Dep25, DP, FP
Silver-S4, ST, INN, Pediatric Dental, Dep25, DP, FP
Gold-G4, ST, INN, Pediatric Dental, Dep25, DP, FP
Platinum-P4, ST, INN, Pediatric Dental, Dep25, DP, FP
Individual Rate 1st Quarter* $543.25 $625.33 $733.06 $856.22 Individual Rate 2nd Quarter* $551.66 $635.01 $744.40 $869.47 Individual Rate 3rd Quarter* $560.20 $644.84 $755.92 $882.92 Individual Rate 4th Quarter* $568.87 $654.82 $767.62 $896.58 Deductible – Individual $4,425 $1,300 $600 $0Deductible – Family $8,850 $2,600 $1,200 $0MOOP – Individual $8,150 $7,900 $4,000 $2,000MOOP – Family $16,300 $15,800 $8,000 $4,000PCP 50% cost sharing $30 copay $25 copay $15 copaySpecialist 50% cost sharing $50 copay $40 copay $35 copayUrgent Care 50% cost sharing $70 copay $60 copay $55 copayAdult Dental / Vision Not covered Not covered Not covered Not coveredPrescription Drugs 30 Days $10/$35/$70 $10/$35/$70 $10/$35/$70 $10/$30/$60Mail Order Rx – 90 days $25/$87.50/$175 $25/$87.50/$175 $25/$87.50/$175 $25/$75/$150
Lab Work 50% cost sharing
Diagnostics(x-ray & blood work)
$50 per visit
Diagnostics(x-ray & blood work)
$40 per visit
Diagnostics(x-ray & blood work)
$35 per visitImaging (MRI, PET, CT)
$50 per visitImaging (MRI, PET, CT)
$40 per visitImaging (MRI, PET, CT)
$35 per visitInpatient (ER/Hospital) 50% cost sharing $250/$1500 $150/$1000 $100/$500Outpatient Surgery (Facility/Physician) 50% cost sharing $150 $100 $100
Exercise Facility Reimbursement
$200 per 6 month period
$200 per 6 month period
$200 per 6 month period
$200 per 6 month period
Pediatric Dental 50% cost sharing $30 copay $25 copay $15 copay
Pediatric Vision 50% cost sharingEye Exam – $30 copay
Glasses – 30% coinsurance
Eye Exam – $25 copayGlasses –
20% coinsurance
Eye Exam – $15 copayGlasses –
10% coinsurance
Other Services Chiropractic & Hearing Aids (50%)
Chiropractic ($50) & Hearing Aids (30%)
Chiropractic ($40) & Hearing Aids (20%)
Chiropractic ($35) & Hearing Aids (10%)
SMALL BUSINESS HEALTH OPTIONS PROGRAM (SHOP)
MetroPlus small business Plans at‑a‑glance 2020
* Multiply individual rate above by 2.00 for Employee + Spouse; by 1.70 for Employee + Child(ren); by 2.85 for Family MBR 19.227
See back for abbreviations/definitions.
nystateofhealth.ny.gov1.855.355.5777TTY: 1.800.662.1220
MetroPlus does not discriminate on the basis of race, color, national origin, sex, age, or disability
in its health programs and activities.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1.800.303.9626 (TTY: 711).
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請致電 1.800.303.9626 (TTY: 711) 。
Rider Definition
ST Standard Plan – Plan was designed by NY State of Health
INN In-Network Coverage Only
Pediatric Dental Pediatric Dental coverage for children age 18 or younger
Dep 25 Dependent coverage through age 25
DP Domestic partners are eligible for coverage
FP Family planning benefit is covered
nystateofhealth.ny.gov1.855.355.5777TTY: 1.800.662.1220
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