| HOSPITAL SERVICES | Empire Plan - Empire BlueCross (Hospital), Network | Empire Plan - United Healthcare (Medical), Participating Provider | Blue Choice | MVP | Highmark Blue Cross Blue Shield | Independent Health |
|---|---|---|---|---|---|---|
|
Hospital Inpatient (surgery) |
No copayment | No copayment | No cost | No cost | No cost | No cost |
|
Hospital Outpatient (surgery) |
$75 or $95 per visit | Network/Hospital $50 per visit, Participating Provider: $25 per visit | Hospital-$50; Physician’s Office- $50 copayment or 20% coinsurance; Outpatient Surgery Facility $25 physician and $50 facility per visit | Hospital/$25, Physician’s Office: PCP/$25 , Outpatient Facility $25 | Hospital/$100, Physician’s Office/$15, Facility/$100 | Hospital/$100, Physician’s Office/$10 (Primary)$20(Specialist), Facility/$100 Child (0-18) Physician’s Office/0 (Primary) $20 Specialist |
| Ambulance | No copayment if service is provided by admitting hospital. | Participating Provider- $70/trip. | $100/trip | $50/trip | $100/trip | $100/trip |
| Emergency Room | $90 or $100/visit | No Copayment | $100/visit | $75/visit | $100/visit | $100/visit |
| Urgent Care | $40 or $50 per outpatient visit at a hospital-owned urgent care facility only. | $30/visit | $35/visit | $15/visit | No copay | $35/visit adult (19+); $0/visit child (0-18) |
| Skilled Nursing Facility | Precertification Required. No copayment | N/A | No cost: 45 days per admission up to a maximum of 360 lifetime limit | No cost up to 45 days | No cost, 100 day maximum | No cost up to 45 days |
| Hospice | No copayment; no limit | No copayment, no limit | No cost; 210 days | No cost, 210 days | No cost | No cost; unlimited |
| PHYSICIAN SERVICES | Empire Plan - Empire BlueCross (Hospital), Network | Empire Plan - United Healthcare (Medical), Participating Provider | Blue Choice | MVP | Highmark Blue Cross Blue Shield | Independent Health |
|---|---|---|---|---|---|---|
| Office Visit | N/A | $25/visit | $25/visit; $5 PCP sick visits for children to age 26, no cost annual exam or well child | No copayment | $10/visit, no cost for child (0-19) | $10/visit, no cost for child (0-18) |
| Specialty Office Visit | N/A | $25/visit | $25/visit | $25/visit |
$15/visit No cost for child (0-19) |
$20/visit |
| Annual Routine Physical | N/A | No Cost | No Cost | No Cost | No Cost | No Cost |
| Chiropractic | N/A | Contact Carrier | Contact Carrier | Contact Carrier | Contact Carrier | Contact Carrier |
| Family Planning | N/A | $25/visit | $25/visit PCP, $25/visit specialist | $25/visit PCP Refer to the certificate of coverage for requirements | $15/visit | $20/visit |
| Infertility Services | $40 or $50 Outpatient | $25/visit; no cost at designated Center of Excellence | Applicable physician/facility copayment | $25/visit PCP Refer to the certificate of coverage for requirements | $15/visit | $20/visit (physician’s office), $100/visit (outpatient surgery center) |
|
Contraceptive Drugs/ Devices |
N/A | No copayment for certain FDA-approved oral contraception methods and counseling | Applicable Rx copay applies - Generic oral contraceptives and certain OTC contraceptive devices are covered in full in accordance with the Affordable Care Act | No cost | No cost | No cost |
| WOMEN’S HEALTH CARE | Empire Plan - Empire BlueCross (Hospital), Network | Empire Plan - United Healthcare (Medical), Participating Provider | Blue Choice | MVP | Highmark Blue Cross Blue Shield | Independent Health |
|---|---|---|---|---|---|---|
| Pap Tests | $40 or $50/outpatient visit | $25 per visit | No cost | No cost | No cost | No cost |
| Mammograms | No Copayment | No Copayment | No cost | No cost | No cost | No cost |
| Pre/Post Natal | N/A | No Copayment, routine OB utrasounds may be subject to $25 copayment | No cost | No cost | $10/final visit only, postnatal visits $10 / visit | No cost |
| Bone Density Tests | $40 or $50/outpatient visit | $25 per visit |
No cost for routine visit $25 Copay (diagnostic) |
No cost | No cost | No cost |
| DIAGNOSTIC / THERAPEUTIC SERVICES | Empire Plan - Empire BlueCross (Hospital), Network | Empire Plan - United Healthcare (Medical), Participating Provider | Blue Choice | MVP | Highmark Blue Cross Blue Shield | Independent Health |
|---|---|---|---|---|---|---|
| Radiology | $40 or $50/outpatient visit | $25/visit | $25/visit | No cost Preferred Provider Facility, $15/PCP $25 Specilaist | $15/visit | $20 Specialist (19+), $0 PCP/$20 Specialist (0-18) |
| Lab Tests | $40 or $50/outpatient visit | $25/visit | No cost | No cost | No cost | No cost |
| Pathology | No cost | $25/visit | No cost | No cost | No cost | No cost |
| EKG/EEG | $40 or $50/outpatient visit | $25/visit | No cost | $25/visit | $15/visit |
$10/PCP $20/Specialist Child (0-18) $0 PCP/$20 Specialist |
| Radiation / Chemo | No Copayment | No Copayment | Radiation $25/visit;Chemo $25 Rx Injection and $25 Office copay - max 2/day | Radiation $25/visit; Chemotherapy $15 PCP $25/Specialist | $15/visit |
Radiation: $20/visit (office, specialty) $40/visit (hospital) Chemo: $10 PCP/$20 Specialist Child (0-18) $0 PCP/$20 Specialist |
| MENTAL HEALTH / SUBSTANCE ABUSE | Empire Plan - Empire BlueCross (Hospital), Network | Empire Plan - United Healthcare (Medical), Participating Provider | Blue Choice | MVP | Highmark Blue Cross Blue Shield | Independent Health |
|---|---|---|---|---|---|---|
| Inpatient Mental Health | N/A | No cost | No cost; unlimited | No cost; unlimited | No cost; unlimited | No cost; unlimited |
| Outpatient Mental Health | N/A | $25/visit | $25/ visit (individual or group); $5 for children to age 26 | No cost, unlimited | $10/visit; unlimited | $10/visit Adult (19+); $0 child (0-18); unlimited |
|
Inpatient Drug / Alcohol Rehab |
N/A | No cost | No cost; unlimited | No cost; unlimited Refer to the certificate of coverage requirements | No cost; unlimited | No cost; unlimited |
|
Outpatient Drug / Alcohol Rehab |
N/A | $25/visit to approved Intensive Outpatient Program. | $25/ visit; $5 for children to age 26 | No cost, unlimited Refer to the certificate of coverage requirements | $10/visit; unlimited | $10/visit Adult (19+); $0 child (0-18); unlimited |
| PRESCRIPTION DRUGS | Empire Plan - Empire BlueCross (Hospital), Network | Empire Plan - United Healthcare (Medical), Participating Provider | Blue Choice | MVP | Highmark Blue Cross Blue Shield | Independent Health |
|---|---|---|---|---|---|---|
|
Prescription Drugs *Note: 3-tier system (generic, preferred brandname drugs, and nonpreferred brand-name drugs) |
Mail order, network pharmacy or speciality pharmacy for 30 day supply: $5, $30, or $60. Mail order or speciality pharmacy for 31-90 day supply: $5, $55, or $110. Network pharmacy 31-90 day supply: $10, $60, or $120. *When you fill a prescription for a brand-name drug that has a generic equivalent you pay the non-preferred brand-name co-payment plus the difference in cost between the brand-name drug and its generic equivalent. | Mail order, network pharmacy or speciality pharmacy for 30 day supply: $5, $30, or $60. Mail order or speciality pharmacy for 31-90 day supply: $5, $55, or $110. Network pharmacy 31-90 day supply: $10, $60, or $120. *When you fill a prescription for a brand-name drug that has a generic equivalent you pay the non-preferred brand-name co-payment plus the difference in cost between the brand-name drug and its generic equivalent. | 30 days retail: $10/$30/$50. 90 days mail order: $20/$60/$100. | 30 days retail: $0/$30/$50. 90 days mail order: $0 /$75 /$125 | 30 days retail: $5/$30/$60. 90 days mail order: $10/$60/$120 No cost for preventative, may require approval | Adult (19+) 30 days retail: $5/$30/$60. 90 days mail order:$12.50/$75/$150 ; Child (0-18) 30 days retail: $0/$30/$60. 90 days mail order:$0/$75/$150 |
| MISCELLANEOUS | Empire Plan - Empire BlueCross (Hospital), Network | Empire Plan - United Healthcare (Medical), Participating Provider | Blue Choice | MVP | Highmark Blue Cross Blue Shield | Independent Health |
|---|---|---|---|---|---|---|
| Centers of Excellence for Cancer and/or Transplant | N/A | No cost at designated Centers of Excellence. Precertification required. | N/A | N/A | N/A | N/A |
| Diabetic Supplies | N/A | No cost. Call HCAP for participating providers. Diabetic Shoes $500 annual max | $25/item; 30 day supply, Diabetic shoes 50% coinsurance | No cost. Refer to the certificate of coverage requirements. Diabetic shoes 50% coinsurance | $10/item, Diabetic shoes not covered | Retail: no copayment, mail order not covered |
|
Durable Medical Equipment |
N/A | No cost. Call HCAP for participating providers. | 50% coinsurance | 50% coinsurance | 50% coinsurance | 50% coinsurance |
| Orthotics | N/A | No copayment | 50% coinsurance | 50% coinsurance | 20% coinsurance | No copayment |
| Prosthetics | N/A | No copayment | 50% coinsurance | 50% coinsurance | 20% coinsurance | 20% coinsurance |
| Rehabilitative Care (PT, OT, Speech) | No copayment as an inpatient; $25 per visit for outpatient physical therapy following related surgery or hospitalization. | Physical or occupational therapy$25 per visit (MPMP)Speech therapy $25 per visit | Inpatient: no cost up to 60 days. Outpatient: $25/visit up to 30 max for all outpatient services combined | Inpatient: no cost, two month max; Outpatient: $15 PCP$25/Specialist up to 30 visits | Inpatient: no cost. Outpatient: $15/visit; max 20 visits. | Inpatient: No cost up to 45 days. Outpatient: $20/visit up to 20 visits per year |
|
Wellness Services: Alternative Medicine, Nutrition, Acupuncture, Massage Therapy |
N/A | Contact Carrier | Up to $500 per family $250 Employee, $250 Spouse/Domestic partner | $600 in WellBeing Rewards | $600 (Single) $750 (family) Wellness card allowance for use at participating providers. Contact for additional programs. | $600 Individual, $750 family. Wellness allowance for use at participating providers. Contact for additional programs |
| Dental (preventive) | N/A | Not covered | $25/when associated with disease or injury | $25/ preventive visit for children up to 19 | Not covered | Discount program available |
| Hearing Aids | N/A | No network benefit. See nonparticipating provider. | Children up to age 19 covered in full for up to two hearing aids every three years. |
50% Coinsurance Single purchase once every 3 years |
50% Coinsurance with participating provider | Discounts available, contact plan for details |
| Vision (routine) | N/A | Not covered | $25/exam every 2 years, children 0-19 one per year. | $25/exam every 24 months | Eye exams covered in full. Eyewear discounts Available | No cost/visit once/year |
| Telehealth | N/A | $25/Visit |
Virtual PCP/Specialist $25/Visit $5 (0-26)/$25 |
Virtual PCP/Specialist $0/$25 |
Virtual PCP/Specialist $10/$15 |
Virtual PCP/Specialist $0/$20 |