Covered Services: All plans offered on the Marketplace cover 10 Essential Health Benefits:

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1 Introduction The NY State of Health 2015 Plan Compare provides information about health plans offered on the Individual Marketplace. Here's some general information to get you started. Metal Levels: Plans offered on the NY State of Health are available at four metal levels: Platinum, Gold, Silver and Bronze. Platinum plans have the lowest out-of-pocket cost if you use a service, but the highest premium. Bronze plans have the highest out-of- pocket cost, but the lowest premium. Covered : All plans offered on the Marketplace cover 10 Essential Health Benefits: Ambulatory Patient Emergency Inpatient Care Maternity and New Born Care Mental Health and Substance Use s Rehabilitative Care Laboratory Preventive, Wellness and Chronic Disease Management Pediatric, including vision care Standard and Non-Standard Plans: NY State of Health offers two types of plans: standard plans and non-standard plans. To make it easier to compare options, standard plans cover the same services and have the same out-of-pocket costs regardless of the insurer. The primary differences are the monthly premium charged by the insurer, the insurer s provider network and prescription drug formulary, and the plan s quality rating. Non-standard plans were designed to give you additional choices. Non-standard plans cover the same ten Essential Health Benefits as the standard plan, but they may also cover extra services like dental and/or vision care for adults. Non-standard plan may also have different out-ofpocket costs.

2 How to Use the NYSOH Plan Compare The Plan Compare is organized by county. Find the section for the county in which you reside. It will include information about all of the health plan options available to you and your family through the Marketplace. At the top of each page, you will find information that identifies the name of the insurer, the name of the plan, the plan s identification number and the metal level. The Plan Compare allows you to preview all of the plan options in your county, or select plans offered by certain insurers or at certain metal levels. Each page in the Health Plan Compare shows the standard plan and the plan you are reviewing so you can see how it compares. Pay particular attention to any difference in out-of-pocket costs and any additional services covered by the plan. The Plan Compare does not include monthly premium because the amount you will pay each month will depend on your income and family size when you apply for coverage. To see if you may qualify for financial assistance to reduce your monthly cost, visit the NY State of Health website. You can review the Plan Compare while you are on the website, or if it is more convenient you can print one or more pages and review them later. The Health Plan Compare is intended to allow you to preview the plans offered on the Individual Marketplace. Before you select and enroll in a health plan, find out which health care providers participate in the health plan s network and, if you take medication, find out if they are covered by the health plans formulary or list of covered drugs. You can find the plan s customer service numbers and provider directory links on our website at: Questions or need assistance? Visit our website at call our Customer Service Center at or meet with a NY State of Health in-person assistor in your area.

3 Livingston County Individual Market Products Plan Standard Non-Standard Excellus X X Fidelis X Health Republic X X MVP X X

4 Plan Name: Excellus Blue Cross Blue Shield Product Name: Bronze Standard Bronze ST INN Dep25 HIOS Plan ID: 78124NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness 0% coinsurance

5 Plan Name: Excellus Blue Cross Blue Shield Product Name: Silver Standard Silver ST INN Dep25 HIOS Plan ID: 78124NY Metal Level: Silver PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness Standard Silver Benefits $5,500 $11,000 $50 copayment copayment $1500 copayment $150 copayment 30% coinsurance $50 copayment $50 copayment $100 copayment

6 Plan Name: Excellus Blue Cross Blue Shield Product Name: Silver Standard Silver ST INN Dep25 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness $50 copayment $1,500 copayment $150 copayment 25% coinsurance $50 copayment $50 copayment $100 copayment

7 Plan Name: Excellus Blue Cross Blue Shield Product Name: Silver Standard Silver ST INN Dep25 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment $50 copayment 10% coinsurance $25 copayment $75 copayment

8 Plan Name: Excellus Blue Cross Blue Shield Product Name: Silver Standard Silver ST INN Dep25 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 PCP Visit Specialist Visit $20 copayment Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $6 copayment $100 copayment $50 copayment 5% coinsurance $25 copayment

9 Plan Name: Excellus Blue Cross Blue Shield Product Name: Gold Standard Gold ST INN Dep25 HIOS Plan ID: 78124NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 PCP Visit $25 copayment Specialist Visit $40 copayment Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment

10 Plan Name: Excellus Blue Cross Blue Shield Product Name: Platinum Standard Platinum ST INN Dep25 HIOS Plan ID: 78124NY Metal Level: Platinum Standard Platinum Benefits PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment

11 Plan Name: Excellus Blue Cross Blue Shield Product Name: Bronze Standard Bronze ST INN Dep29 HIOS Plan ID: 78124NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness 0% coinsurance

12 Plan Name: Excellus Blue Cross Blue Shield Product Name: Silver Standard Silver ST INN Dep29 HIOS Plan ID: 78124NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 PCP Visit Specialist Visit $50 copayment Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $1500 copayment $150 copayment 30% coinsurance $50 copayment $50 copayment $100 copayment

13 Plan Name: Excellus Blue Cross Blue Shield Product Name: Silver Standard Silver ST INN Dep29 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness $50 copayment $1,500 copayment $150 copayment 25% coinsurance $50 copayment $50 copayment $100 copayment

14 Plan Name: Excellus Blue Cross Blue Shield Product Name: Silver Standard Silver ST INN Dep29 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment $50 copayment 10% coinsurance $25 copayment $75 copayment

15 Plan Name: Excellus Blue Cross Blue Shield Product Name: Silver Standard Silver ST INN Dep29 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 PCP Visit Specialist Visit $20 copayment Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $6 copayment $100 copayment $50 copayment 5% coinsurance $25 copayment

16 Plan Name: Excellus Blue Cross Blue Shield Product Name: Gold Standard Gold ST INN Dep29 HIOS Plan ID: 78124NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 PCP Visit $25 copayment Specialist Visit $40 copayment Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment

17 Plan Name: Excellus Blue Cross Blue Shield Product Name: Platinum Standard Platinum ST INN Dep29 HIOS Plan ID: 78124NY Metal Level: Platinum Standard Platinum Benefits PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment

18 Plan Name: Excellus Product Name: Bronze Select Bronze NS INN Dep29 HIOS Plan ID: 78124NY Metal Level: Bronze Standard Bronze Benefits How Does this Non-Standard $3,000 $6,000 $4,500 $9,000 $6,350 $12,700 $6,350 $12,700 PCP Visit Specialist Visit Preventive Care 0% coinsurance copayment 40% coinsurance Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care

19 Plan Name: Excellus Product Name: Bronze Select Bronze NS INN Dep25 HIOS Plan ID: 78124NY Metal Level: Bronze Standard Bronze Benefits How Does this Non-Standard $3,000 $6,000 $4,500 $9,000 $6,350 $12,700 $6,350 $12,700 PCP Visit Specialist Visit Preventive Care 0% coinsurance copayment 40% coinsurance Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Not covered Pediatric Vision Care

20 Plan Name: Excellus Product Name: Silver Select Silver NS INN Dep29 HIOS Plan ID: 78124NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard $5,500 $11,000 $5,000 $10,000 PCP Visit 20% coinsurance Specialist Visit $50 copayment 20% coinsurance Preventive Care copayment copayment $45 copayment $90 copayment Inpatient $1500 copayment 20% coinsurance Emergency Room $150 copayment 20% coinsurance Urgent Care 20% coinsurance Durable Medical Equipment 30% coinsurance Covered Therapies 20% coinsurance Diagnostic & Routine Lab $50 copayment 20% coinsurance Diagnostic & Routine $50 copayment 20% coinsurance Outpatient Surgery $100 copayment 20% coinsurance Home Health Care 20% coinsurance Outpatient Behavioral Health 20% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care 20% coinsurance

21 Plan Name: Excellus Product Name: Silver Select Silver NS INN Dep29 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 How Does this Non-Standard $5,200 $10,400 $3,000 $6,000 PCP Visit 20% coinsurance Specialist Visit $50 copayment 20% coinsurance Preventive Care copayment $5 copayment $45 copayment $90 copayment Inpatient $1,500 copayment 20% coinsurance Emergency Room $150 copayment 20% coinsurance Urgent Care 20% coinsurance Durable Medical Equipment 25% coinsurance Covered Therapies 20% coinsurance Diagnostic & Routine Lab $50 copayment 20% coinsurance Diagnostic & Routine $50 copayment 20% coinsurance Outpatient Surgery $100 copayment 20% coinsurance Home Health Care 20% coinsurance Outpatient Behavioral Health 20% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care 20% coinsurance

22 Plan Name: Excellus Product Name: Silver Select Silver NS INN Dep29 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 How Does this Non-Standard $250 $500 $1,650 $3,300 PCP Visit 20% coinsurance Specialist Visit 20% coinsurance Preventive Care copayment copayment $9 copayment $20 copayment $40 copayment $5 copayment $45 copayment $90 copayment Inpatient $250 copayment 20% coinsurance Emergency Room $75 copayment 20% coinsurance Urgent Care $50 copayment 20% coinsurance Durable Medical Equipment 10% coinsurance Covered Therapies $25 copayment 20% coinsurance Diagnostic & Routine Lab 20% coinsurance Diagnostic & Routine 20% coinsurance Outpatient Surgery $75 copayment 20% coinsurance Home Health Care 20% coinsurance Outpatient Behavioral Health 20% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care 20% coinsurance

23 Plan Name: Excellus Product Name: Silver Select Silver NS INN Dep29 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $1,650 $3,300 PCP Visit 5% coinsurance Specialist Visit $20 copayment 5% coinsurance Preventive Care copayment copayment $6 copayment How Does this Non-Standard $5 copayment Inpatient $100 copayment 5% coinsurance Emergency Room $50 copayment 5% coinsurance Urgent Care 5% coinsurance Durable Medical Equipment 5% coinsurance Covered Therapies 5% coinsurance Diagnostic & Routine Lab 5% coinsurance Diagnostic & Routine 5% coinsurance Outpatient Surgery $25 copayment 5% coinsurance Home Health Care 5% coinsurance Outpatient Behavioral Health 5% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care 5% coinsurance

24 Plan Name: Excellus Product Name: Silver Select Silver NS INN Dep25 HIOS Plan ID: 78124NY Metal Level: Silver Standard Bronze Benefits How Does this Non-Standard $5,500 $11,000 $5,000 $10,000 PCP Visit 20% coinsurance Specialist Visit $50 copayment 20% coinsurance Preventive Care copayment copayment $45 copayment $90 copayment Inpatient $1500 copayment 20% coinsurance Emergency Room $150 copayment 20% coinsurance Urgent Care 20% coinsurance Durable Medical Equipment 30% coinsurance Covered Therapies 20% coinsurance Diagnostic & Routine Lab $50 copayment 20% coinsurance Diagnostic & Routine $50 copayment 20% coinsurance Outpatient Surgery $100 copayment 20% coinsurance Home Health Care 20% coinsurance Outpatient Behavioral Health 20% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care 20% coinsurance

25 Plan Name: Excellus Product Name: Silver Select Silver NS INN Dep25 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 How Does this Non-Standard $5,200 $10,400 $3,000 $6,000 PCP Visit 20% coinsurance Specialist Visit $50 copayment 20% coinsurance Preventive Care copayment $5 copayment $45 copayment $90 copayment Inpatient $1,500 copayment 20% coinsurance Emergency Room $150 copayment 20% coinsurance Urgent Care 20% coinsurance Durable Medical Equipment 25% coinsurance Covered Therapies 20% coinsurance Diagnostic & Routine Lab $50 copayment 20% coinsurance Diagnostic & Routine $50 copayment 20% coinsurance Outpatient Surgery $100 copayment 20% coinsurance Home Health Care 20% coinsurance Outpatient Behavioral Health 20% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care 20% coinsurance

26 Plan Name: Excellus Product Name: Silver Select Silver NS INN Dep25 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 How Does this Non-Standard $250 $500 $1,650 $3,300 PCP Visit 20% coinsurance Specialist Visit 20% coinsurance Preventive Care copayment copayment $9 copayment $20 copayment $40 copayment $5 copayment $45 copayment $90 copayment Inpatient $250 copayment 20% coinsurance Emergency Room $75 copayment 20% coinsurance Urgent Care $50 copayment 20% coinsurance Durable Medical Equipment 10% coinsurance Covered Therapies $25 copayment 20% coinsurance Diagnostic & Routine Lab 20% coinsurance Diagnostic & Routine 20% coinsurance Outpatient Surgery $75 copayment 20% coinsurance Home Health Care 20% coinsurance Outpatient Behavioral Health 20% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care 20% coinsurance

27 Plan Name: Excellus Product Name: Silver Select Silver NS INN Dep25 HIOS Plan ID: 78124NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $1,650 $3,300 PCP Visit 5% coinsurance Specialist Visit $20 copayment 5% coinsurance Preventive Care copayment copayment $6 copayment How Does this Non-Standard $5 copayment Inpatient $100 copayment 5% coinsurance Emergency Room $50 copayment 5% coinsurance Urgent Care 5% coinsurance Durable Medical Equipment 5% coinsurance Covered Therapies 5% coinsurance Diagnostic & Routine Lab 5% coinsurance Diagnostic & Routine 5% coinsurance Outpatient Surgery $25 copayment 5% coinsurance Home Health Care 5% coinsurance Outpatient Behavioral Health 5% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care 5% coinsurance

28 Plan Name: Excellus Product Name: Gold Select Gold NS INN Dep29 HIOS Plan ID: 78124NY Metal Level: Gold Standard Gold Benefits How Does this Non-Standard $600 $1,200 $600 $1,200 $8,000 $8,000 PCP Visit $25 copayment $25 copayment Specialist Visit $40 copayment $40 copayment Preventive Care copayment copayment $5 copayment Inpatient $1,000 copayment $750 copayment Emergency Room $150 copayment $250 copayment Urgent Care $60 copayment $40 copayment Durable Medical Equipment 20% coinsurance Covered Therapies $40 copayment Diagnostic & Routine Lab $40 copayment $25 copayment Diagnostic & Routine $40 copayment $40 copayment Outpatient Surgery $100 copayment 0% coinsurance Home Health Care $25 copayment Outpatient Behavioral Health $40 copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care $40 copayment

29 Plan Name: Excellus Product Name: Gold Select Gold NS INN Dep25 HIOS Plan ID: 78124NY Metal Level: Gold Standard Gold Benefits How Does this Non-Standard $600 $1,200 $600 $1,200 $8,000 $8,000 PCP Visit $25 copayment $25 copayment Specialist Visit $40 copayment $40 copayment Preventive Care copayment copayment $5 copayment Inpatient $1,000 copayment $750 copayment Emergency Room $150 copayment $250 copayment Urgent Care $60 copayment $40 copayment Durable Medical Equipment 20% coinsurance Covered Therapies $40 copayment Diagnostic & Routine Lab $40 copayment $25 copayment Diagnostic & Routine $40 copayment $40 copayment Outpatient Surgery $100 copayment 0% coinsurance Home Health Care $25 copayment Outpatient Behavioral Health $40 copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care $40 copayment

30 Plan Name: Excellus Product Name: Platinum Select Platinum NS INN Dep29 HIOS Plan ID: 78124NY Metal Level: Platinum Standard Platinum Benefits How Does this Non-Standard $6,350 $12,700 PCP Visit Specialist Visit $25 copayment Preventive Care copayment copayment $60 copayment $5 copayment $25 copayment $60 copayment Inpatient $500 copayment $150 copayment Emergency Room $100 copayment $75 copayment Urgent Care $60 copayment $25 copayment Durable Medical Equipment 20% coinsurance Covered Therapies $25 copayment Diagnostic & Routine Lab Diagnostic & Routine $25 copayment Outpatient Surgery $100 copayment copayment Home Health Care Outpatient Behavioral Health $25 copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care $25 copayment

31 Plan Name: Excellus Product Name: Platinum Select Platinum NS INN Dep25 HIOS Plan ID: 78124NY Metal Level: Platinum Standard Platinum Benefits How Does this Non-Standard $6,350 $12,700 PCP Visit Specialist Visit $25 copayment Preventive Care copayment copayment $60 copayment $5 copayment $25 copayment $50 copayment Inpatient $500 copayment $150 copayment Emergency Room $100 copayment $75 copayment Urgent Care $60 copayment $25 copayment Durable Medical Equipment 20% coinsurance Covered Therapies $25 copayment Diagnostic & Routine Lab Diagnostic & Routine $25 copayment Outpatient Surgery $100 copayment copayment Home Health Care Outpatient Behavioral Health $25 copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care $25 copayment

32 Plan Name: Fidelis Care Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness 0% coinsurance

33 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Silver PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness Standard Silver Benefits $5,500 $11,000 $50 copayment copayment $1500 copayment $150 copayment 30% coinsurance $50 copayment $50 copayment $100 copayment

34 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness $50 copayment $1,500 copayment $150 copayment 25% coinsurance $50 copayment $50 copayment $100 copayment

35 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment $50 copayment 10% coinsurance $25 copayment $75 copayment

36 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 PCP Visit Specialist Visit $20 copayment Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $6 copayment $100 copayment $50 copayment 5% coinsurance $25 copayment

37 Plan Name: Fidelis Care Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 PCP Visit $25 copayment Specialist Visit $40 copayment Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment

38 Plan Name: Fidelis Care Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep25 HIOS Plan ID: 25303NY Metal Level: Platinum Standard Platinum Benefits PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment

39 Plan Name: Fidelis Care Product Name: Fidelis Care Bronze ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Bronze Standard Bronze Benefits $3,000 $6,000 $6,350 $12,700 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness 0% coinsurance

40 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Silver Standard Silver Benefits $5,500 $11,000 PCP Visit Specialist Visit $50 copayment Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $1500 copayment $150 copayment 30% coinsurance $50 copayment $50 copayment $100 copayment

41 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 $5,200 $10,400 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness $50 copayment $1,500 copayment $150 copayment 25% coinsurance $50 copayment $50 copayment $100 copayment

42 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $9 copayment $20 copayment $40 copayment $250 copayment $75 copayment $50 copayment 10% coinsurance $25 copayment $75 copayment

43 Plan Name: Fidelis Care Product Name: Fidelis Care Silver ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 PCP Visit Specialist Visit $20 copayment Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $6 copayment $100 copayment $50 copayment 5% coinsurance $25 copayment

44 Plan Name: Fidelis Care Product Name: Fidelis Care Gold ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Gold Standard Gold Benefits $600 $1,200 $8,000 PCP Visit $25 copayment Specialist Visit $40 copayment Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $1,000 copayment $150 copayment $60 copayment 20% coinsurance $40 copayment $40 copayment $100 copayment

45 Plan Name: Fidelis Care Product Name: Fidelis Care Platinum ST INN Pediatric Dental Dep29 HIOS Plan ID: 25303NY Metal Level: Platinum Standard Platinum Benefits PCP Visit Specialist Visit Preventive Care Inpatient Emergency Room Urgent Care Durable Medical Equipment Covered Therapies Diagnostic & Routine Lab Diagnostic & Routine Outpatient Surgery Home Health Care Outpatient Behavioral Health Pediatric Basic Dental Care Pediatric Vision Care Wellness copayment $60 copayment $500 copayment $100 copayment $60 copayment 20% coinsurance $100 copayment

46 Plan Name: Health Republic Insurance Product Name: Primary Select Bronze NS INN Dep 25 Acupuncture HIOS Plan ID: 71644NY Metal Level: Bronze Standard Bronze Benefits How Does this Non-Standard $3,000 $6,000 Additional Non-Standard Benefits: Acupuncture $5,500 $11,000 $6,350 $12,700 $6,350 $12,700 PCP Visit $75 copayment Specialist Visit $75 copayment Preventive Care 0% coinsurance copayment Inpatient 20% coinsurance Emergency Room $300 coinsurance Urgent Care $100 coinsurance Durable Medical Equipment 20% coinsurance Covered Therapies $75 coinsurance Diagnostic & Routine Lab $75 coinsurance Diagnostic & Routine $75 copayment Outpatient Surgery 20% coinsurance Home Health Care $75 copayment Outpatient Behavioral Health $75 copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care $75 copayment

47 Plan Name: Health Republic Insurance Product Name: Primary Select Bronze NS INN Dep29 Acupuncture HIOS Plan ID: 71644NY Metal Level: Bronze Standard Bronze Benefits How Does this Non-Standard Additional Non-Standard Benefits: Acupuncture $5,500 $11,000 $5,500 $11,000 $6,350 $12,700 PCP Visit $75 copayment Specialist Visit $50 copayment $75 copayment Preventive Care copayment $ copayment Inpatient $1500 copayment 20% coinsurance Emergency Room $150 copayment $300 coinsurance Urgent Care $100 coinsurance Durable Medical Equipment 30% coinsurance 20% coinsurance Covered Therapies $75 coinsurance Diagnostic & Routine Lab $50 copayment $75 coinsurance Diagnostic & Routine $50 copayment $75 copayment Outpatient Surgery $100 copayment 20% coinsurance Home Health Care $75 copayment Outpatient Behavioral Health $75 copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care $75 copayment

48 Plan Name: Health Republic Insurance Product Name: Total Independence Bronze NS INN Dep 25 Acupuncture Massage Therapy Naturopathy HIOS Plan ID: 71644NY Metal Level: Bronze Standard Bronze Benefits How Does this Non-Standard $6,000 $12,000 $5,500 $11,000 $6,500 $13,000 PCP Visit copayment Specialist Visit $50 copayment copayment Preventive Care copayment copayment copayment copayment Inpatient $1500 copayment copayment Emergency Room $150 copayment copayment Urgent Care $100 coinsurance Durable Medical Equipment 30% coinsurance 20% coinsurance Covered Therapies $75 coinsurance Diagnostic & Routine Lab $50 copayment $75 coinsurance Diagnostic & Routine $50 copayment $75 copayment Outpatient Surgery $100 copayment 20% coinsurance Home Health Care $75 copayment Outpatient Behavioral Health $75 copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care $75 copayment Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

49 Plan Name: Health Republic Insurance Product Name: Total Independence Bronze NS INN Dep29 Acupuncture Massage Therapy Naturopathy HIOS Plan ID: 71644NY Metal Level: Bronze Standard Bronze Benefits How Does this Non-Standard $6,000 $12,000 $5,500 $11,000 $6,500 $13,000 PCP Visit copayment Specialist Visit $50 copayment copayment Preventive Care copayment copayment copayment copayment Inpatient $1500 copayment copayment Emergency Room $150 copayment copayment Urgent Care $75 copayment Durable Medical Equipment 30% coinsurance copayment Covered Therapies copayment Diagnostic & Routine Lab $50 copayment copayment Diagnostic & Routine $50 copayment copayment Outpatient Surgery $100 copayment copayment Home Health Care copayment Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care copayment Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

50 Plan Name: Health Republic Insurance Product Name: Primary Select Silver NS INN Dep 25 Acupuncture HIOS Plan ID: 71644NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard Additional Non-Standard Benefits: Acupuncture $5,500 $11,000 $6,350 $12,700 PCP Visit copayment Specialist Visit $50 copayment $75 copayment Preventive Care copayment copayment Inpatient $1500 copayment 20% coinsurance Emergency Room $150 copayment $250 copayment Urgent Care $100 copayment Durable Medical Equipment 30% coinsurance 20% coinsurance Covered Therapies $75 coinsurance Diagnostic & Routine Lab $50 copayment $75 copayment Diagnostic & Routine $50 copayment $75 copayment Outpatient Surgery $100 copayment 20% coinsurance Home Health Care Outpatient Behavioral Health 20% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care

51 Plan Name: Health Republic Insurance Product Name: Primary Select Silver NS INN Dep 25 Acupuncture HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 Additional Non-Standard Benefits: Acupuncture How Does this Non-Standard $5,200 $10,400 $4,500 $9,000 PCP Visit copayment Specialist Visit $50 copayment $75 copayment Preventive Care copayment copayment Inpatient $1,500 copayment 20% coinsurance Emergency Room $150 copayment $250 copayment Urgent Care $100 copayment Durable Medical Equipment 25% coinsurance 20% coinsurance Covered Therapies Diagnostic & Routine Lab $50 copayment $75 copayment Diagnostic & Routine $50 copayment $75 copayment Outpatient Surgery $100 copayment 20% coinsurance Home Health Care Outpatient Behavioral Health 20% copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care

52 Plan Name: Health Republic Insurance Product Name: Primary Select Silver NS INN Dep 25 Acupuncture HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 $1,750 $3,500 PCP Visit copayment Specialist Visit $75 copayment Preventive Care copayment copayment $9 copayment $20 copayment $40 copayment Additional Non-Standard Benefits: Acupuncture How Does this Non-Standard $20 copayment $40 copayment Inpatient $250 copayment 20% coinsurance Emergency Room $75 copayment $250 copayment Urgent Care $50 copayment $100 copayment Durable Medical Equipment 10% coinsurance 20% coinsurance Covered Therapies $25 copayment Diagnostic & Routine Lab $75 copayment Diagnostic & Routine $75 copayment Outpatient Surgery $75 copayment 20% coinsurance Home Health Care $25 copayment Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care $25 copayment

53 Plan Name: Health Republic Insurance Product Name: Primary Select Silver NS INN Dep 25 Acupuncture HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $500 $1,000 PCP Visit copayment Specialist Visit $20 copayment $75 copayment Preventive Care copayment copayment $6 copayment Additional Non-Standard Benefits: Acupuncture How Does this Non-Standard Inpatient $100 copayment 20% coinsurance Emergency Room $50 copayment $250 copayment Urgent Care $100 copayment Durable Medical Equipment 5% coinsurance 20% coinsurance Covered Therapies Diagnostic & Routine Lab $75 copayment Diagnostic & Routine $75 copayment Outpatient Surgery $25 copayment 20% coinsurance Home Health Care Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care

54 Plan Name: Health Republic Insurance Product Name: Primary Select Silver NS INN Dep29 Acupuncture HIOS Plan ID: 71644NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard Additional Non-Standard Benefits: Acupuncture $5,500 $11,000 $6,350 $12,700 PCP Visit copayment Specialist Visit $50 copayment $75 copayment Preventive Care copayment copayment Inpatient $1500 copayment 20% coinsurance Emergency Room $150 copayment $250 copayment Urgent Care $100 copayment Durable Medical Equipment 30% coinsurance 20% coinsurance Covered Therapies Diagnostic & Routine Lab $50 copayment $75 copayment Diagnostic & Routine $50 copayment $75 copayment Outpatient Surgery $100 copayment 20% coinsurance Home Health Care Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care

55 Plan Name: Health Republic Insurance Product Name: Primary Select Silver NS INN Dep29 Acupuncture HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 Additional Non-Standard Benefits: Acupuncture How Does this Non-Standard $5,200 $10,400 $4,500 $9,000 PCP Visit copayment Specialist Visit $50 copayment $75 copayment Preventive Care copayment copayment Inpatient $1,500 copayment 20% coinsurance Emergency Room $150 copayment $250 copayment Urgent Care $100 copayment Durable Medical Equipment 25% coinsurance 20% coinsurance Covered Therapies Diagnostic & Routine Lab $50 copayment $75 copayment Diagnostic & Routine $50 copayment $75 copayment Outpatient Surgery $100 copayment Home Health Care Outpatient Behavioral Health 20% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care

56 Plan Name: Health Republic Insurance Product Name: Primary Select Silver NS INN Dep29 Acupuncture HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 $1,750 $3,500 PCP Visit copayment Specialist Visit $75 copayment Preventive Care copayment copayment $9 copayment $20 copayment $40 copayment Additional Non-Standard Benefits: Acupuncture How Does this Non-Standard $20 copayment Inpatient $250 copayment 20% coinsurance Emergency Room $75 copayment $250 copayment Urgent Care $50 copayment $100 copayment Durable Medical Equipment 10% coinsurance 20% coinsurance Covered Therapies $25 copayment Diagnostic & Routine Lab $75 copayment Diagnostic & Routine $75 copayment Outpatient Surgery $75 copayment 20% coinsurance Home Health Care $25 copayment Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care $25 copayment

57 Plan Name: Health Republic Insurance Product Name: Primary Select Silver NS INN Dep29 Acupuncture HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $500 $1,000 PCP Visit copayment Specialist Visit $20 copayment $75 copayment Preventive Care copayment copayment $6 copayment Additional Non-Standard Benefits: Acupuncture How Does this Non-Standard Inpatient $100 copayment 20% coinsurance Emergency Room $50 copayment $250 copayment Urgent Care $100 copayment Durable Medical Equipment 5% coinsurance 20% coinsurance Covered Therapies Diagnostic & Routine Lab $75 copayment Diagnostic & Routine $75 copayment Outpatient Surgery $25 copayment 20% coinsurance Home Health Care Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care

58 Plan Name: Health Republic Insurance Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy Naturopathy HIOS Plan ID: 71644NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard $3,800 $7,600 $5,500 $11,000 $4,300 $8,600 PCP Visit copayment Specialist Visit $50 copayment copayment Preventive Care copayment copayment $20 copayment copayment copayment Inpatient $1500 copayment copayment Emergency Room $150 copayment $250 copayment Urgent Care $75 copayment Durable Medical Equipment 30% coinsurance 0% coinsurance Covered Therapies copayment Diagnostic & Routine Lab $50 copayment $20 copayment Diagnostic & Routine $50 copayment copayment Outpatient Surgery $100 copayment copayment Home Health Care copayment Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care copayment Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

59 Plan Name: Health Republic Insurance Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy Naturopathy HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 How Does this Non-Standard $3,000 $6,000 $5,200 $10,400 $3,600 $7,200 PCP Visit copayment Specialist Visit $50 copayment copayment Preventive Care copayment copayment $20 copayment copayment copayment Inpatient $1,500 copayment copayment Emergency Room $150 copayment $250 copayment Urgent Care $75 copayment Durable Medical Equipment 25% coinsurance 0% coinsurance Covered Therapies copayment Diagnostic & Routine Lab $50 copayment $20 copayment Diagnostic & Routine $50 copayment copayment Outpatient Surgery $100 copayment copayment Home Health Care copayment Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care copayment Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

60 Plan Name: Health Republic Insurance Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy Naturopathy HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 How Does this Non-Standard $700 $1,400 $1,300 $2,600 PCP Visit 0% coinsurance Specialist Visit 0% coinsurance Preventive Care copayment 0% coinsurance $9 copayment $20 copayment $40 copayment $20 copayment 0% coinsurance 0% coinsurance Inpatient $250 copayment copayment Emergency Room $75 copayment $250 copayment Urgent Care $50 copayment $75 copayment Durable Medical Equipment 10% coinsurance copayment Covered Therapies $25 copayment 0% coinsurance Diagnostic & Routine Lab $20 copayment Diagnostic & Routine 0% coinsurance Outpatient Surgery $75 copayment 0% coinsurance Home Health Care 0% coinsurance Outpatient Behavioral Health 0% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care 0% coinsurance Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

61 Plan Name: Health Republic Insurance Product Name: Total Independence Silver NS INN Dep 25 Acupuncture Massage Therapy Naturopathy HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $500 $1,000 PCP Visit copayment Specialist Visit $20 copayment copayment Preventive Care copayment copayment $6 copayment How Does this Non-Standard Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy $20 copayment copayment copayment Inpatient $100 copayment copayment Emergency Room $50 copayment $250 copayment Urgent Care $75 copayment Durable Medical Equipment 5% coinsurance 0% coinsurance Covered Therapies copayment Diagnostic & Routine Lab $20 copayment Diagnostic & Routine copayment Outpatient Surgery $25 copayment copayment Home Health Care copayment Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care copayment

62 Plan Name: Health Republic Insurance Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy Naturopathy HIOS Plan ID: 71644NY Metal Level: Silver Standard Silver Benefits How Does this Non-Standard $3,800 $7,600 $5,500 $11,000 $4,300 $8,600 PCP Visit copayment Specialist Visit $50 copayment copayment Preventive Care copayment copayment $20 copayment copayment copayment Inpatient $1500 copayment copayment Emergency Room $150 copayment $250 copayment Urgent Care $75 copayment Durable Medical Equipment 30% coinsurance 0% coinsurance Covered Therapies copayment Diagnostic & Routine Lab $50 copayment $20 copayment Diagnostic & Routine $50 copayment copayment Outpatient Surgery $100 copayment copayment Home Health Care copayment Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care copayment Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

63 Plan Name: Health Republic Insurance Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy Naturopathy HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,200 $2,400 How Does this Non-Standard $3,000 $6,000 $5,200 $10,400 $3,600 $7,200 PCP Visit copayment Specialist Visit $50 copayment copayment Preventive Care copayment copayment $20 copayment copayment copayment Inpatient $1,500 copayment copayment Emergency Room $150 copayment $250 copayment Urgent Care $75 copayment Durable Medical Equipment 25% coinsurance 0% coinsurance Covered Therapies copayment Diagnostic & Routine Lab $50 copayment $20 copayment Diagnostic & Routine $50 copayment copayment Outpatient Surgery $100 copayment copayment Home Health Care copayment Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care copayment Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

64 Plan Name: Health Republic Insurance Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy Naturopathy HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $250 $500 How Does this Non-Standard $700 $1,400 $1,300 $2,600 PCP Visit 0% coinsurance Specialist Visit 0% coinsurance Preventive Care copayment 0% coinsurance $9 copayment $20 copayment $40 copayment $20 copayment 0% coinsurance 0% coinsurance Inpatient $250 copayment copayment Emergency Room $75 copayment $250 copayment Urgent Care $50 copayment $75 copayment Durable Medical Equipment 10% coinsurance copayment Covered Therapies $25 copayment 0% coinsurance Diagnostic & Routine Lab $20 copayment Diagnostic & Routine 0% coinsurance Outpatient Surgery $75 copayment 0% coinsurance Home Health Care 0% coinsurance Outpatient Behavioral Health 0% coinsurance Pediatric Basic Dental Care Not covered Pediatric Vision Care 0% coinsurance Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy

65 Plan Name: Health Republic Insurance Product Name: Total Independence Silver NS INN Dep29 Acupuncture Massage Therapy Naturopathy HIOS Plan ID: 71644NY Metal Level: Silver Cost Share Reduction, % FPL Standard Silver Benefits, % FPL $1,000 $500 $1,000 PCP Visit copayment Specialist Visit $20 copayment copayment Preventive Care copayment copayment $6 copayment How Does this Non-Standard Additional Non-Standard Benefits: Acupuncture, Massage Therapy, Naturopathy $20 copayment 0% coinsurance 0% coinsurance Inpatient $100 copayment copayment Emergency Room $50 copayment $250 copayment Urgent Care $75 copayment Durable Medical Equipment 5% coinsurance copayment Covered Therapies copayment Diagnostic & Routine Lab $20 copayment Diagnostic & Routine copayment Outpatient Surgery $25 copayment copayment Home Health Care copayment Outpatient Behavioral Health copayment Pediatric Basic Dental Care Not covered Pediatric Vision Care copayment

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