| Benefits |
NYSBA Premier PPO $25 |
NYSBA Plus PPO $30 |
NYSBA Comprehensive PPO $40 |
NYSBA Basic EPO $40 |
| Annual Deductible |
$500/individual; $1,000/family |
$1,500/individual; $3,000/family |
$3,000/individual; $6,000/family |
$1,500/individual; $3,000/family |
| Coinsurance |
100% |
MVP Covers 80% After Deductible |
MVP Covers 80% After Deductible |
MVP Covers 80% After Deductible |
| Annual Out of Pocket Max |
$2,000/individual; $4,000/family |
$5,000/individual; $10,000/family |
$10,000/individual; $20,000/family |
$5,000/individual; $10,000/family |
| Preventive Care |
$25 Copay (Except Well Child Services Covered in Full) |
Covered in Full |
Covered in Full |
Covered in Full |
| Hospital Inpatient |
$500 Copay (1st admission only) |
Ded & Coinsurance |
Deductible & Coinsurance |
Deductible & Coinsurance |
| Therapy Services (Office Setting) |
$25 Copay |
$30 Copay |
$40 Copay |
$40 Copay |
| Prescription Drug |
$10/30/50 Unlimited |
$10/30/50 Unlimited |
$10/30/50 with $4,000 Annual Max |
$10 Unlimited Generic Only/ MVP Discounted Rate on Brand Medications |
| Out-of-Network Services |
Deductible: $2,500/indiv.; $5,000/family Coinsurance: MVP Covers 60% Annual OOP Max: $12,500/indiv.; $25,000/family Lifetime Max: $1,000,000 |
Deductible: $3,000/indiv.; $6,000/family Coinsurance: MVP Covers 60% Annual OOP Max: $10,000/indiv.; $20,000/family Lifetime Max: $500,000 |
Deductible: $6,000/indiv.; $12,000/family Coinsurance: MVP Covers 60% Annual OOP Max: $20,000/indiv.; $40,000/family Lifetime Max: $500,000 |
In-Network Only Benefits |