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NYSHIP Certificate of Insurance

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.

January 1, 2016 Empire Plan Copayments

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

Office Surgery - $20

(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

(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: - No copayment

Adult Immunizations for Herpes Zoster (Shingles) immunization for enrollees age 55 and over but under age 60 - Paid-in-full benefit for covered adult immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers 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

Anesthesiology, Radiology, Pathology in connection with inpatient or outpatient network hospital services - No copayment

Free-standing Cardiac Rehabilitation Center visit - $20 Copayment

Urgent Care Center - $20 Copayment

Convenience Care Clinic Visit - $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

Medically appropriate professional 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 - $60 Copayment*
(The $60 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.)

Network Hospital Outpatient Department Services

Surgery - $40 Copayment*

Diagnostic Laboratory Tests - $30 Copayment*

Diagnostic Radiology (including mammography, according to guidelines) - $30 Copayment*

Administration of Desferal for Cooley's Anemia - $30 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 ($40 copayment if surgery is included; $30 copayment if 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.

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 - $60 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 Service Pharmacy or the Designated Specialty Pharmacy

$5 Copayment – Generic Drugs or Level 1 Drugs
$25 Copayment – Preferred Brand-name Drugs, Compound Drugs or Level 2 Drugs
$45 Copayment – Non-preferred Brand-name Drugs or Level 3 Drugs**

31 to 90-day supply from a network pharmacy

$10 Copayment – Generic Drugs or Level 1 Drugs
$50 Copayment – Preferred Brand-name Drugs, Compound Drugs or Level 2 Drugs
$90 Copayment – Non-preferred Brand-name Drugs or Level 3 Drugs**

31 to 90-day supply through the Mail Service Pharmacy

$5 Copayment – Generic Drugs or Level 1 Drugs
$50 Copayment – Preferred Brand-name Drugs, Compound Drugs or Level 2 Drugs
$90 Copayment – Non-preferred Brand-name Drugs or Level 3 Drugs**

*Note: Oral chemotherapy drugs for the treatment of cancer do not require a copayment and covered services defined as preventive under the Patient Protection and Affordable Care Act are not subject to copayment.
**If you choose to purchase a brand-name drug that has a generic equivalent, you pay the non-preferred brand-name copayment plus the difference in cost between the brand-name drug and its generic equivalent (with some exceptions), not to exceed the full cost of the drug.