Applicable Inpatient Hospital Surgery or Outpatient Surgery copayment

Applicable Inpatient Hospital Surgery or Outpatient Surgery copayment

Basic Medical

The Empire Plan has a Specialty Pharmacy Program; see Choices for details.

The Empire Plan provides network and non-network inpatient and outpatient hospital coverage for medical, surgical and maternity care. Medical coverage is provided under the Participating Provider Program, the Basic Medical Program and Basic Medical Provider Discount Program.

Center of Excellence Programs are available for cancer, transplants, infertility and substance use disorder*; coverage provided for inpatient and outpatient mental health and substance use; and prescription drug coverage, unless it is provided by a union Employee Benefit Fund.

*The Center of Excellence for Substance Use Disorder is available to Empire Plan-primary enrollees only.

Other benefits include home care services, durable medical equipment and certain medical supplies (including diabetic and ostomy supplies), enteral formulas and diabetic shoes through the Home Care Advocacy Program (HCAP). Coverage for physical therapy, occupational therapy and chiropractic treatment through the Managed Physical Medicine Program (MPMP).

Voluntary Disease Management Programs available for conditions such as asthma, attention deficit disorder (ADHD), cardiovascular disease (CAD), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), congestive heart failure, depression, diabetes and eating disorders.

24-hour NurseLine for health information and support at 1-877-7-NYSHIP (1-877-769-7447).

Benefits are available worldwide.

For information regarding covered vaccines, tests and screenings, see the Empire Plan Preventive Care Coverage Guide on the NYSHIP website under Publications or visit www.hhs.gov/healthcare/rights/preventive-care.

Under The Empire Plan, you can choose from over 1.2 million participating physicians and other providers nationwide.

Provides coverage for medical services, such as office visits, surgery and diagnostic testing under the Participating Provider Program, or under the Basic Medical and Basic Medical Provider Discount Programs if you choose a nonparticipating provider.

Voluntary outpatient medical case management is available to help coordinate services for serious and complex cases.

The Empire Plan provides coverage for inpatient and outpatient services provided by a hospital or skilled nursing facility, as well as hospice care.

When you use a network hospital, medical or surgical stays are covered at no cost to you. Other provider charges will also be paid in full. In certain cases, The Empire Plan will approve network benefits at a non-network facility.

Also provides inpatient Benefits Management Program services, including preadmission certification of hospital admissions and admission or transfer to a skilled nursing facility, concurrent reviews, discharge planning, inpatient medical case management and the Building Healthy Families (formerly Future Moms) program.

* The Prescription Drug Program does not apply to those who have drug coverage through a union Employee Benefit Fund.

Under The Empire Plan, you can choose from more than 66,000 participating pharmacies or a mail service pharmacy.

A pharmacist is available 24 hours a day, seven days a week to answer questions about your prescriptions.

Prior authorization is required for certain drugs.

Certain covered drugs for the treatment of cancer, generic oral contraceptive drugs and devices, brand-name contraceptive drugs and devices without a generic equivalent, medications used for emergency contraception and pregnancy termination as well as certain preventive adult vaccinations do not require a copayment when using a network pharmacy.

The Empire Plan has a flexible formulary that excludes certain prescription drugs from coverage. An excluded drug is not subject to any type of appeal or coverage review, including a medical-necessity appeal.

The Empire Plan Specialty Pharmacy Program offers enhanced services to individuals using specialty drugs, such as those used to treat complex conditions and those that require special handling, special administration or intensive patient monitoring.

NOTE: Medicare-primary retirees and dependents covered under The Empire Plan each are enrolled automatically in Empire Plan Medicare Rx, a Part D prescription drug program. Each Medicare-primary individual will receive a unique ID number and Empire Plan Medicare Rx Card to use at the pharmacy.

If you are an active employee, The Empire Plan provides primary coverage for you and your dependents, regardless of age or disability. Exceptions: Medicare is primary for domestic partners age 65 or over or for an active employee or dependent of an active employee with end-stage renal disease (following a 30-month coordination period).

NYSHIP requires you and your dependents to be enrolled in Medicare Parts A and B when first eligible for Medicare coverage that pays primary to NYSHIP. If you or a dependent is eligible for Medicare coverage primary to NYSHIP and you don't enroll in Parts A and B, The Empire Plan will not provide benefits for services Medicare would have paid if you or your dependent had enrolled.

If you are enrolled in original Medicare (Parts A and B) and have secondary coverage under The Empire Plan, The Empire Plan coordinates benefits with Medicare. Since Medicare does not provide coverage outside the United States, The Empire Plan pays primary for covered services received outside the United States.

You can be enrolled in only one Medicare plan at a time. Enrolling in a Medicare plan separate from your NYSHIP coverage may drastically reduce your benefits overall, and in most cases, you will be automatically disenrolled from your Empire Plan benefits.

NOTE: Medicare is primary for your same-sex spouse/domestic partner age 65 or over, or for an active employee or dependent with end-stage renal disease who would otherwise be Empire Plan primary (following a 30-month coordination period).