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.

The Center of Excellence Program is available for cancer, transplants, infertility and substance use disorder*; coverage provided for inpatient mental health and substance use, outpatient mental health and substance use, and prescription drug coverage (unless provided by a union employee benefit fund).

*The Center of Excellence for Substance Use Disorder Program 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).

Coordination with Medicare.

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 "Current Publications," or visit hhs.gov/healthcare/rights/preventive-care.

Under The Empire Plan, you can choose from over one 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 and other provider charges are covered at no cost to you. 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 program.

* Empire Plan Medicare Rx 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 60,000 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.

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.

The Empire Plan Medicare Rx formulary includes Medicare Part D covered drugs and a secondary list of additional (non-Part D) drugs that are covered as part of a supplemental benefit.

Prescriptions covered under Medicare Part B are covered under The Empire Plan's Medical/Surgical benefit and are excluded from Empire Plan Medicare Rx. For example, Medicare covers certain oral chemotherapy drugs under your Part B benefit (not Part D). Because they're covered under Medicare first and The Empire Plan's Medical/Surgical benefit second, the pharmacy should bill Medicare directly for all Part B medications. Most pharmacies already know which Medicare program covers which drugs.

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.

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.

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.

Enrolling in a non-NYSHIP Medicare product in addition to your NYSHIP coverage may drastically reduce your benefits overall and, in most cases, will result in the cancellation of your NYSHIP coverage.

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).