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MetroPlusHealth Gold is available to all NYC employees, non-Medicare eligible retirees,
their spouses or qualified domestic partners, and eligible dependents. $0* copays
$0 doctor visits, $0 unlimited telehealth, $0 mental health care, Up to $1,400 to work
out at the gym.Our network includes 34,000+ of the City’s top doctors, 40+ hospitals
including NYU Langone, Mount Sinai, and NY Health + Hospitals, and 110+ urgent care
centers, including CityMD locations.
At a Glance
Plan Type:
HMO
Geographic Service Area
MetroPlusHealth service area includes Manhattan, Brooklyn, Queens, the Bronx and
Staten Island.
Does this plan use a network of providers?
Yes. Visit the Web site at www.metroplus.org for the most current list of
participating providers.
Do I need a referral to see a specialist?
While a written referral is not required, all referrals should still be directed by the member’s PCP.
Contact Information
877.475.3795 Representatives are available Monday through Friday 8AM to 6PM and
Saturday 9am to 5pm.
Web Site
www.metroplus.org
Plan Features
Cost
What is the overall deductible for this plan?
• $0
What are the costs when you visit a health
care provider’s office or clinic?
• Primary care visit to treat an injury or illness: No charge. Not covered for
non-participating providers.
• Specialist visit: No charge. Not covered for non-participating providers.
• Other practitioner office visit Chiropractor: No charge. Not covered for
non-participating providers.
• Preventive care/screening/immunization: No charge. Not covered for
non-participating providers.
• Adult physical examinations, Mammograms (limits based on age), Cervical cytology,
Routine gynecological services, Bone density exams, Screening for Prostate & Colon
cancer (limits based on age).
What are the costs if you have a test?
• Diagnostic test (x-ray, blood work): No charge.
• Not covered for non-participating providers.
• Imaging (CT/PET scans, MRIs): No charge.
• Not covered for non-participating providers
What are the costs if you have outpatient
surgery?
• Facility fee (e.g., ambulatory surgery center): No charge.
• Not covered for non-participating providers.
• Physician/surgeon fees: No charge.
• Not covered for non-participating providers.
What are the costs if you need immediate
medical attention?
• Emergency room services: $100 Copay, waived if admitted.
• Emergency medical transportation: No charge.
• No charge for non-participating providers.
• Urgent Care: $25 Copay.
• Not covered for non-participating providers.
What are the costs if you have a hospital
stay?
• •Facility fee (e.g., hospital room): No charge.
• Not covered for non-participating providers.
• Physician/surgeon fee: No charge. Not covered for non-participating providers.
What are the costs if you are pregnant?
• Prenatal and postnatal care: No charge. Not covered for non-participating providers.
METROPLUSHEALTH GOLD
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WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• No charge
• Not covered for non-participating provider
Mental/Behavioral health
Inpatient services
• No charge
• Not covered for non-participating provider
• Unlimited days per calendar year
Substance abuse
Outpatient services
• No charge
• Not covered for non-participating provider
Substance abuse
Inpatient services
• No charge
• Not covered for non-participating provider
• Unlimited days per calendar year
What are the costs if you need help recovering or have other special health needs?
Service
Cost
Home health care
• No charge
• Not covered for non-participating provider
• Coverage limited to 40 visits per year
Rehabilitation services
• No charge
• Not covered for non-participating provider
• 20 visits per condition, per year combined therapies
Habilitation services
• No charge
• Not covered for non-participating provider
• 20 visits per condition, per year combined therapies
Skilled nursing care
• No charge
• Not covered for non-participating provider
• 200 days per Plan Year
Durable medical equipment (DME)
• 0% coinsurance
• Not covered for non-participating provider
Hospice service
• No charge
• Not covered for non-participating provider
• 210 days per plan year/ Five (5) visits for family bereavement counseling
What is the cost if you need drugs to treat your illness or condition?
Grandfathered RX1 Rider Retail – 30 Day Supply
Mail Order – 90 Day Supply
Generic drugs (Tier 1)
$0 copayment
$0 copayment
Brand drugs (Tier 2)
$35 copayment
$70 copayment
Non-formulary (Tier 3)
$70 copayment
$140 copayment
New Member RX2 Rider Retail – 30 Day Supply
Mail Order – 90 Day Supply
Generic drugs (Tier 1)
20% copayment
20% copayment
Brand drugs (Tier 2)
40% copayment
40% copayment
Non-formulary (Tier 3)
50% copayment
50% copayment
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
• Delivery and all inpatient services: No charge. Not covered for non-participating providers.
Limited to 48 hours for natural delivery and 96 hours for caesarean delivery.
OPTIONAL RIDER
