thRed Platinum NS OON Limited PCP Network Dep25
18029NY1180016
Platinum
POS
thRed Platinum NS OON Limited PCP Network Dep25 is a Platinum POS plan by Independent Health Benefits Corporation.
Locations
thRed Platinum NS OON Limited PCP Network Dep25 is offered in the following counties.
Plan Overview
This is a plan overview for 2022 version of thRed Platinum NS OON Limited PCP Network Dep25 18029NY1180016.
| Insurer: | Independent Health Benefits Corporation |
| Network Type: | POS |
| Metal Type: | Platinum |
| HSA Eligible?: | No |
| Plan ID: | 18029NY1180016 |
Cost-Sharing Overview
thRed Platinum NS OON Limited PCP Network Dep25 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for thRed Platinum NS OON Limited PCP Network Dep25 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | 5250 | 5250 per person | $10500 per group |
| Deductible: | 0 | 0 per person | $0 per group |
| Coinsurance: | 0 per person | $0 per group | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for thRed Platinum NS OON Limited PCP Network Dep25 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | ||
| Out-of-Network Deductible: | 5000 | 10000 per person | $10000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | 0 |
| Copayment: | 600 |
| Coinsurance: | 0 |
| Limit: | 60 |
| Deductible: | 0 |
| Copayment: | 80 |
| Coinsurance: | 0 |
| Limit: | 60 |
| Deductible: | 0 |
| Copayment: | 500 |
| Coinsurance: | 20 |
| Limit: | 0 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for thRed Platinum NS OON Limited PCP Network Dep25?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
thRed Platinum NS OON Limited PCP Network Dep25 offers the following features and referral requirements.
| Wellness Program: | Yes |
| Disease Program: | |
| Notice Pregnancy: | No |
| Referral Specialist: | Yes |
| Specialist Requiring Referral: | All |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what thRed Platinum NS OON Limited PCP Network Dep25 covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | Emergency Only |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Emergency services and Urgent Care Centers covered as in-network; all other services covered at deductible and coinsurance |
| National Network: | No |
Additional Benefits and Cost-Sharing
thRed Platinum NS OON Limited PCP Network Dep25 includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Specialist Visit Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Transplant Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Bariatric Surgery Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Mental/Behavioral Health Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Acupuncture Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Well Baby Visits and Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Inpatient Rehabilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Inpatient Physician and Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Reconstructive Surgery Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Major Dental Care – Child Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Accidental Dental Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Imaging (CT/PET Scans, MRIs) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Durable Medical Equipment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Dental Check-Up for Children Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Abortion for Which Public Funding is Prohibited Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Procedure(s) per Year Other Law/Regulation |
| Contact Lenses for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Item(s) per Year Additional EHB Benefit |
| Prenatal and Postnatal Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Nutritional Counseling Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Diabetes Education Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Routine Eye Exam (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Assistive Communication Devices Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Rehabilitative Speech Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 60 Visit(s) per Year 60 visits per condition per year combined. Speech therapy is only covered following a hospital stay or surgery. |
| Orthodontia – Child Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Generic Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Non-Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Preadmission Testing Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Emergency Room Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Cochlear Implants Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | One per ear per time CoveredAdditional EHB Benefit |
| Treatment for Temporomandibular Joint Disorders Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Coverage includes surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery. |
| Cosmetic Surgery Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Orthodontia – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Emergency Transportation/Ambulance Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Cardiac Rehabilitation Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Infertility Treatment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Covers services for the diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease, or dysfunction. |
| Routine Dental Services (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Delivery and All Inpatient Services for Maternity Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Chemotherapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Chiropractic Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Medications Administered in an Office or Outpatient Setting Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Prostate Cancer Screening Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Breast Reconstructive Surgery Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Outpatient Surgery Physician/Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Eye Glasses for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Item(s) per Year One prescribed lenses & frames in a 12-month period. |
| Major Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Autologous Blood Banking Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Urgent Care Centers or Facilities Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Second Opinion Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Skilled Nursing Facility Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 365 Days per Year Additional EHB Benefit |
| Long-Term/Custodial Nursing Home Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Laboratory Outpatient and Professional Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Primary Care Visit to Treat an Injury or Illness Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Basic Dental Care – Child Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Outpatient Rehabilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 60 Visit(s) per Year 60 visits per condition per year combined. Physical and speech therapy are only covered following a hospital stay or surgery. |
| Wellness Benefit Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Earn a $50 allowance for Subscriber and Covered Spouse for completing the onboarding process and up to an additional $450 in allowances per Subscriber.Additional EHB Benefit |
| Substance Abuse Disorder Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Hospice Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 210 Days per Year Also includes 5 visits for family bereavement counseling. |
| Family Planning Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Medical Supplies Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Hearing Aids Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Item(s) per 3 Years Covers a single purchase (including repair and/or replacement) of hearing aids for one or both ears once every three years. |
| Home Health Care Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 40 Visit(s) per Year Each visit of up to four hours by a home health aide is one visit. |
| X-rays and Diagnostic Imaging Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Allergy Testing Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Dialysis Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Preventive Care/Screening/Immunization Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 60 Visit(s) per Year 60 visits per condition per year combined. Physical therapy is only covered following a hospital stay or surgery. |
| Private-Duty Nursing Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Weight Loss Programs Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Applied Behavior Analysis Based Therapies Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Diabetic Equipment and Supplies Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Design Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | This plan requires referrals to access care for members 21 years of age and older. This plan offers access to select Primary Care Physicians within the Independent Health network. The deductible applies per family (non-embedded). The wellness benefit for this plan is different from the New York Standard Gym Benefit, offering a $50 allowance for Subscriber and Covered Spouse for completing the onboarding process and up to an additional $450 in allowances per Subscriber.Additional EHB Benefit |
| Routine Foot Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Telemedicine Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Specialty Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Substance Abuse Disorder Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Also includes 20 visits per year for family counseling. |
| Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Routine Eye Exam for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Exam(s) per Year |
| Mental/Behavioral Health Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Basic Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Not EHB |
| Sterilization Procedures for Men Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Additional EHB Benefit |
| Habilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 60 Visit(s) per Year Services consisting of physical therapy, speech therapy, and occupational therapy, in the outpatient department of a Facility or in a Health Care Professional’s office. |
| Prosthetic Devices Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | One external prosthetic device per limb per lifetime with coverage for repairs and replacements (limit does not apply to internal devices) |
| Radiation Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Infusion Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Any visits for home infusion therapy count towards Your home health care visit limit. |
Free Preventive Services
There is no copayment or coinsurance for any of the following thRed Platinum NS OON Limited PCP Network Dep25 preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Ready to sign up for thRed Platinum NS OON Limited PCP Network Dep25?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904