TIER 1
TIER 2
Summary of Benefits and Coverage (SBC)
Sample SBC: 3K PLAN
This is a brief outline of benefits. It is not a Summary Plan Description or intended to replace the Schedule of Benefits contained within the Plan Document. If any provision is inconsistent with the language of the Plan Document, the Plan Document will govern.
Medical Benefits
Tier 1
Deductible
Max out-of-Pocket
Coinsurance
Preventive Care
Primary Care Visit
Specialist Visit
$2,000/$4,000
$7,500/$18,200
80% for chemo
No Charge
$35
$45
Tier 2
Deductible
Max out-of-Pocket
Coinsurance
Preventive Care
Primary Care Visit
Specialist Visit
$3,000/$6,000
$7,500/$18,200
70% for chemo
No Charge
$45
$55
Out-of-Network
Deductible
Max out-of-Pocket
Coinsurance
Preventive Care
Primary Care Visit
Specialist Visit
$6,000/$12,000
$9,200/$18,200
60%
Deductible/Co-Ins
Deductible/Co-Ins
Deductible/Co-Ins
Pharmacy Benefits
Retail Pharmacy
Supply
Generic
Preferred
Non-Preferred
30 Days
$10
$60
$80
Mail Order Pharmacy
Supply
Generic
Preferred
Non-Preferred
90 Days
$30
$180
$240
FAQs
Health Plans
The plan designs shown are currently in use. Employers who establish a standalone plan have the flexibility to make changes. We’ve addressed some common questions on this topic and welcome any additional feedback.
Questions?
For enrollment inquiries contact:
Dom Maggiore
Memberly
(631) 905-6555
dom.maggiore@memberlybenefits.com
Copays and Deductible
Yes, the copay is the only cost for the visit itself. However, if additional services are provided during the visit, they may be subject to applicable copays, deductibles, and coinsurance
Copays for primary care and specialist visits are listed on your ID card. Additional copay details can be found in the Summary of Benefits and Coverage (SBC). Your provider can also confirm the applicable copay for your visit.
Yes, preventive care services, including annual physicals and screenings, are covered at no cost to you, with no copay, deductible, or coinsurance required.
All deductible payments, regardless of tier, cross-accumulate throughout the year, helping to minimize the member's out-of-pocket costs by ensuring all eligible expenses contribute toward meeting the deductible.
All deductible payments, regardless of tier, cross-accumulate toward both the individual and family deductibles, ensuring that all covered expenses contribute to meeting the plan’s deductible requirements.
2-Tier Network
A two-tier network structure lowers out-of-pocket costs for members who utilize Tier 1 providers, while also reducing the overall cost of the health plan for all members by steering utilization toward more cost-effective healthcare providers.
Yes, you can continue using your current providers within the Blue Cross Blue Shield network. If your provider is also part of the Northwell network, your claim will automatically be processed at the lower Tier 1 rate.
No problem! That’s why the plan includes Blue Cross Blue Shield as its National PPO network. You can visit any Blue Cross Blue Shield hospital, facility, or provider for coverage.
No. Northwell Direct is not an insurance carrier. The 2tier plan is contracted with an employer is a self finded health plan mamaged by a third partry administrator (TPA).
Find Care
Visit www.Anthem.com and use the location search tool. Before starting your search, enter the prefix "NDA" in the search field. For a more personalized experience, register and log in to the Anthem website.
Visit www.Northwell.edu/find-care and use the location search.