Empire Plan Copayments
See your Empire Plan Certificates and Empire Plan Reports for details, including preadmission and prior authorization requirements, services that do not require copayments and limitations. If you have a question, call 1-877-7-NYSHIP (1-877-769-7447) toll free and select the appropriate program from the menu.
Medical/Surgical Program*
* Note: Covered services defined as preventive under the Patient Protection and Affordable Care Act are not subject to copayment.
| Service | Copayment |
|---|---|
| Office Visit, Office Surgery, Radiology, Diagnostic Laboratory Tests, Free-standing Cardiac Rehabilitation Center Visit, Convenience Care Clinic Visit | $25 |
| Non-hospital Urgent Care Center Visit | $30 |
| Non-hospital Outpatient Surgical Locations | $50 |
| Licensed Ambulance Service | $70 |
Chiropractic Treatment or Physical Therapy Services (Managed Physical Medicine Program)
| Service | Copayment |
|---|---|
| Office Visit, Radiology, Diagnostic Laboratory Tests | $25 |
Hospital Program
| Service | Copayment |
|---|---|
| Outpatient Physical Therapy | $25 |
| Urgent Care Center Visit, Outpatient Services for Diagnostic Radiology and Diagnostic Laboratory Tests in a network Hospital or Hospital Extension Clinic | $50 |
| Outpatient Surgery | $95 |
| Emergency Department Visit | $100 |
Mental Health and Substance Use Program
| Service | Copayment |
|---|---|
| Visit to Outpatient Substance Use Treatment Program | $25 |
| Visit to Mental Health Professional | $25 |
| Emergency Department Visit | $100 |
Prescription Drug Program**
** Certain covered drugs do not require a copayment when using a Network Pharmacy:
- Oral chemotherapy drugs, when prescribed for the treatment of cancer
- Generic oral contraceptive drugs and devices or brand-name contraceptive drugs/devices without a generic equivalent (single-source brand-name drugs/devices), with up to a 12-month supply of contraceptives at one time without an initial 3-month supply
- Tamoxifen, raloxifene, anastrozole and exemestane when prescribed for women age 35 and over for the primary prevention of breast cancer
- Pre-Exposure Prophylaxis (PrEP), when prescribed for enrollees who are at high risk of acquiring HIV
- Certain preventive adult vaccines when administered by a licensed pharmacist at a pharmacy that participates in the CVS Caremark national vaccine network
- Certain prescription and over-the-counter medications*** that are recommended for preventive services without cost sharing and have in effect a rating of “A” or “B” in the current recommendations of the U.S. Preventive Services Task Force (USPSTF)
*** When available over-the-counter, USPSTF “A” and “B” rated medications require a prescription order to process without cost sharing.
Medicare-primary enrollees or dependents should refer to the Empire Plan Medicare Rx Evidence of Coverage for prescription copayment amounts.
| Up to a 30-day supply from a Network Pharmacy or through the Mail Service Pharmacy or the Specialty Pharmacy | Copayment |
|---|---|
| Level 1 Drugs or for Most Generic Drugs | $5 |
| Level 2 Drugs, Preferred Drugs or Compound Drugs | $30 |
| Level 3 Drugs or Non-preferred Drugs | $60 |
| 31- to 90-day supply from a Network Pharmacy | Copayment |
|---|---|
| Level 1 Drugs or for Most Generic Drugs | $10 |
| Level 2 Drugs, Preferred Drugs or Compound Drugs | $60 |
| Level 3 Drugs or Non-preferred Drugs | $120 |
| 31- to 90-day supply through the Mail Service Pharmacy or the Specialty Pharmacy | Copayment |
|---|---|
| Level 1 Drugs or for Most Generic Drugs | $5 |
| Level 2 Drugs, Preferred Drugs or Compound Drugs | $55 |
| Level 3 Drugs or Non-preferred Drugs | $110 |