This online publication has been updated to include the Amendments through January 1, 2014. For details such as the effective dates of amendments, see your group-specific amendments in the Publications & Forms section of this site.
Here's a guide to your copayments for services covered under The Empire Plan. See your Empire Plan Certificates for details.
Services by Empire Plan Participating Providers
You pay only your copayment when you choose Empire Plan Participating Providers for covered services. Check your directory for Participating Providers in your geographic area, or ask your provider. For Empire Plan Participating Providers in other areas and to check a provider's current status, call The Empire Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and choose UnitedHealthcare or use the online Participating Provider Directory.
Office Visit: $20 Copayment
Office Surgery: $20 Copayment
(If there are both an Office Visit charge and an Office Surgery charge by a Participating Provider in a single visit, only one copayment will apply, in addition to any copayment due for Radiology/Laboratory Tests.)
Radiology, Single or Series; Diagnostic Laboratory Tests: $20 Copayment
(If Outpatient Radiology and Outpatient Diagnostic Laboratory Tests are charged by a Participating Provider during a single visit, only one copayment will apply, in addition to any copayment due for Office Visit/Office Surgery.)
Routine Mammography Screening: $20 Copayment
Outpatient (group and individual therapy visits): $40 to $55 copay Cost share may vary depending on where service is provided. Skilled nursing facility (SNF). $0 copay per day for days 1-20. $178 copay per day for days 21-55. $0 copay per day for days 56-100. Your plan covers up to 100 days in aSNF Physical Therapy. $40 copay. . A copay applies for any care received for a medical condition that’s treated or monitored during a preventive visit. We follow the Centers for Medicare & Medicaid Services (CMS) Medicare. Coverage and coding guidelines for all network services. You can view Coverage Summaries on UHCprovider.com. On MDsave, the cost of an MRI ranges from $313 to $3,074. Those on high deductible health plans or without insurance can shop, compare prices and save. Read more about how MDsave works. MRI or Magnetic Resonance Imaging is a medical testing procedure that physicians use to image different parts of the body.
Adult Immunizations: $20 Copayment for Herpes Zoster (Shingles) immunization for enrollees age 55 and over but under age 60. Paid in full benefit for adult immunizations as recommended by the Advisory Committee on Immunization Practices of the Center of Disease Control and Prevention when received from a participating provider.
Allergen Immunotherapy: No Copayment
Well-Child Office Visit, including Routine Pediatric Immunizations: No Copayment
Prenatal Visits and Six-Week Check-Up after Delivery: No Copayment
Chemotherapy, Radiation Therapy, Dialysis: No Copayment
Authorized care at Infertility Center of Excellence: No Copayment
Hospital-based Cardiac Rehabilitation Center: No Copayment
Free-standing Cardiac Rehabilitation Center Visit: $20 Copayment
Urgent Care Center: $20 Copayment
Contraceptive Drugs and Devices when dispensed in a doctor's office: $20 Copayment*
(in addition to any copayment(s) due for Office Visit/Office Surgery and Radiology/Laboratory Tests)
*Copayment waived for preventive services under the federal Patient Protection and Affordable Care Act (PPACA). See NYSHIP Online for details. Diagnostic services require Plan copayment or coinsurance.
Outpatient Surgical Locations (including Anesthesiology and same-day pre-operative testing done at the center): $30 Copayment
Medically appropriate local commercial ambulance transportation: $35 Charge
Chiropractic Treatment or Physical Therapy Services by Managed Physical Network (MPN) Providers
You pay only your copayment when you choose MPN network providers for covered services. To find an MPN network provider, ask the provider directly, or call UnitedHealthcare at 1-877-7-NYSHIP (1-877-769-7447) toll free. Internet: https://www.cs.ny.gov.
Office Visit: $20 Copayment
Radiology; Diagnostic Laboratory Tests: $20 Copayment
(If Radiology and Laboratory Tests are charged by an MPN network provider during a single visit, only one copayment will apply, in addition to any copayment due for Office Visit.)
Hospital Outpatient Department Services
Emergency Care: $70 Copayment
(The hospital outpatient copayment covers use of the facility for Emergency Room Care, including services of the attending emergency room physician and providers who administer or interpret radiological exams, laboratory tests, electrocardiogram and pathology services.)
Surgery: $60 Copayment*
Diagnostic Laboratory Tests: $40 Copayment*
Diagnostic Radiology (including mammography, according to guidelines): $40 Copayment*
Administration of Desferal for Cooley's Anemia: $40 Copayment*
Physical Therapy (following related surgery or hospitalization): $20 Copayment
Chemotherapy, Radiation Therapy, Dialysis: No Copayment
Pre-Admission Testing/Pre-Surgical Testing prior to inpatient admission: No Copayment
*Only one copayment ($60 copayment if surgery is included; $40 is diagnostic outpatient services only) per visit will apply for all covered hospital outpatient services rendered during that visit. The copayment covers the outpatient facility. Provider services may be billed separately. You will not have to pay the facility copayment if you are treated in the outpatient department of a hospital and it becomes necessary for the hospital to admit you, at that time, as an inpatient.
Be sure to follow Benefits Management Program requirements for hospital admissions, skilled nursing facility admission and Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine tests.
The Empire Plan Mental Health and Substance Abuse Services by Network Providers When You Are Referred by Beacon Health Options
Call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) toll-free before beginning treatment.
Visit to Outpatient Substance Abuse Treatment Program: $20 Copayment
Visit to Mental Health Professional: $20 Copayment
Emergency Room Care: $70 Copayment
Psychiatric Second Opinion when Pre-Certified: No Copayment
Mental Health Crisis Intervention (three visits): No Copayment
Inpatient: No Copayment
Empire Plan Prescription Drugs*
Note: Medicare-primary enrollees or dependents should refer to the Empire Plan Medicare Rx Evidence of Coverage for prescription copayment amounts
(Only one copayment applies for up to a 90-day supply.)
Up to a 30-day supply from a network pharmacy or through the Mail Order Pharmacy or the Designated Specialty Pharmacy
$5 Copayment – Level 1 Drugs or most Generic Drugs
$25 Copayment – Level 2, Preferred Drugs or Compound Drugs
$45 Copayment – Level 3 or Non-preferred Drugs**
31 to 90-day supply from a network pharmacy
$10 Copayment –Level 1 Drugs or most Generic Drugs
$50 Copayment –Level 2, Preferred Drugs or Compound Drugs
$90 Copayment – Level 3 or Non-preferred Drugs**
31 to 90-day supply through the Mail Order Pharmacy or the Designated Specialty Pharmacy
$5 Copayment –Level 1 Drugs or most Generic Drugs
$50 Copayment –Level 2, Preferred Drugs or Compound Drugs
$90 Copayment – Level 3 or Non-preferred Drugs**
*Note: Oral chemotherapy drugs for the treatment of cancer do not require a copayment. In addition, generic oral contraceptive drugs and devices or brand-name drugs/devices without a generic equivalent (single-source brand-name drugs/devices) do not require a copayment.
**If you choose to purchase a brand-name drug that has a generic equivalent, you will pay the non-preferred drug copayment plus the difference in cost between the brand-name drug and its generic equivalent (with some exceptions), not to exceed the full retail cost of the covered drug.
Mri Copay Assistance
***Covered services defined as preventive under the Patient Protection and Affordable Care Act are not subject to copayment.