| Benefits |
NYSAPLS Comprehensive EPO $30 |
NYSAPLS Plus EPO $30 |
NYSAPLS Premier EPO $25 |
| Annual Deductible |
$1,500/individual; $3,000/family |
$750/individual; $1,500/family |
$500/individual; $1,000/family |
| Coinsurance |
MVP Covers 80% After Deductible |
MVP Covers 80% After Deductible |
MVP Covers 100% After Deductible |
| Annual Out of Pocket Max |
$5,000/individual; $10,000/family |
$2,500/individual; $5,000/family |
$2,000/individual/ $4,000/family |
| Preventive Care |
Covered in Full |
Covered in Full |
$25 Copay (Except Well Child Services Covered in Full) |
| Hospital Inpatient |
Deductible & Coinsurance |
Deductible & Coinsurance |
$500 Copay (1st admission only) |
| Therapy Services (Office Setting) |
$30 Copay |
$30 Copay |
$25 Copay |
| Prescription Drug |
$10/25/40 with $4,000 Annual Max |
$10/25/40 with $2,500 Max then 50% Coverage |
$10/30/50 Unlimited Rx |