44 | Page
What is the overall medical deductible for this
plan?
GHI: In-network: $0
Out-of-network: $200 individual/$500 family
What is the out-of-pocket limit on my
expenses (applies to in-network services
only)?
For 7/01/23 – 6/30/24 the limit is $4,550 individual/$9,100 family.
AnthemBCBS Hospital:
For 7/01/23 – 6/30/24 the limit is $2,600 individual/$5,200 family.
Visit emblemhealth.com/city for a full list of
Preventive services are available with $0 copayments when using a participating provider.
What are the costs when you visit an
AdvantageCare Physician’s (ACPNY) office?
• ACPNY primary care visit to treat an injury or illness: $0 copay/visit
• ACPNY specialist visit: $0 copay/visit
care provider’s office?
• In-network primary care visit to treat an injury or illness: $15 copay/visit
• ACPNY: $0 copay/visit
• Non-participating provider: After deductible is met 0% coinsurance
• In-network specialist visit: $30 co-pay/visit
• Non-participating provider: After deductible is met 0% coinsurance
• In-network other practitioner office visit: $15 copay/visit
• Non-participating provider: After deductible is met 0% coinsurance
• In-network preventive care/screening/immunization: $0 copay/visit
• Non-participating provider: After deductible is met 0% coinsurance
• Teladoc is an easy, convenient way to access doctors for treatment of non-emergency
conditions, including cold and flu symptoms, respiratory infections, sinus problems,
bronchitis, skin problems, and allergies.
• Visit Teladoc/Emblemhealth or call 800-835-2362 (800-Teladoc) (TTY: 711) to set up your
account. Once you register, you are just a call or click away from getting treatment.
• In-network diagnostic test (x-ray, blood work): $20 co-pay/visit
• Non-participating provider: After the deductible is met 0% co-insurance
• In-network imaging (CT/PET scans, MRIs): $50 co-pay for Preferred providers, $100 copay
for Non-preferred providers. (Pre-certification required)
• Non-participating provider: After deductible is met 0% co-insurance
surgery?
• AnthemBCBS: Facility fee:
In-network: 20% coinsurance of allowed amount to a maximum of $200 per
person per calendar year.
Out-of-Network provider: $500 deductible per person per visit and 20%
coinsurance per person and balance billing.
• GHI: Physician/surgeon fees:
In-network: Covered
Non-participating provider: After deductible is met 0% co-insurance
You must call NYC Healthline 1-800- 521-9574 for pre-certification.
medical attention?
• AnthemBCBS: Emergency room services:
In-network: $150 copay/visit; Co-pay waived if admitted.
Out-of-network: $150 copay/visit; Co-pay waived if admitted
• GHI: Emergency medical transportation:
In-network: Not covered
Out-of-network: 100% of the 80% percentile of Fair Health
• GHI: Urgent Care:
In-network: $50 copay/visit Preferred $100 copay/visit Non-preferred
Non-participating provider: After the deductible is met 0% co-insurance
• GHI: Physician/surgeon fees:
In-network: Covered
Non-participating provider: After the deductible is met 0% co-insurance
• ANTHEM: Facility fee (e.g., hospital room):
In-network (e.g., hospital room): $300 per person up to $750 maximum individual co-