Your Summary of Benefits
Empire Prismsm Deductible First PPO
For Groups with 51+ Eligible Employees
Option
In-Network Deductible*
Out-of-Network Cost Sharing Options***
(Member Responsibility)**
(Member Responsibility)
Deductible*
Coinsurance
Coinsurance
Stop-Loss
Total Out of Network Out-of-Pocket
Maximum (Includes OON Deductible)
3A
$250 or $500
$1000
20%
30%
$10,000
$3,000
$4,000
3B
$250 or $500
$1000
20%
30%
$25,000
$6,000
$8,500
3C
$250, $500, $750, or $1000
$2000
20%
30%
$10,000
$4,000
$5,000
3D
$250, $500, $750, or $1000
$2000
20%
30%
$25,000
$7,000
$9,500
3E
$250, $500, $750, or $1000, $1500 or
$5000
20%
30%
$10,000
$7,000
$8,000
$5000
20%
30%
$25,000
$10,000
$12,500
$2000
3F
$250, $500, $750, or $1000, $1500 or
$2000
*Unless otherwise indicated, In-Network Deductible must be satisfied before member cost-share applies. INN covered preventive care covered at 100%, all other services
subjected to deductible. Out of Network Deductible selected must be $500 higher than the In-Network Deductible.
**Family coverage is 2.5 times the individual coverage amount.
***INN and OON deductibles accumulate separately and do not apply toward each other.
Benefit
Lifetime Maximum
Dependent Children (covered to the end
of the month of the dependent’s
birthday)
In-Network 1
Unlimited
Dependents to Age 26
Out-of-Network 2,3
Unlimited
Same as In-Network
Options
Dependents through Age 29 (Covered to the end of
the month of Dependent’s 30th birthday. Dependent
must live, work, or reside in New York state and
meet other eligibility requirements)
Dependents through Age 29 (Covered to the
end of the month of Dependent’s 30th birthday.
Dependent must meet other eligibility
requirements)
Out-of-Pocket maximum
$5,080/$12,700 (All In-Network medical &
RX cost share)
Member Pays In-Network
$0 copayment
$0 copayment
$0 copayment
See above chart
Deductible and Coinsurance
Member Pays Out-of-Network
Does not apply
Urgent Care Center
$0 copayment
Member Pays In-Network
PCP- $5-$50 Spec $5-$75
(PCP/Spec in $5 increments) after
deductible)
Specialist Copayment after Deductible
Emergency Room/Facility
( initial visit per occurrence)
$150 copayment (waived if admitted within
24 hours) after deductible
Online Visits
Deductible and Coinsurance
Ambulatory Surgery4/Outpatient Surgery
PCP Copayment option apply after
deductible
$100 copay after deductible
Presurgical Testing, Anesthesia
Chemotherapy, Radiation Therapy
Routine Maternity Care
$0 after deductible
$0 after deductible
$0 after deductible
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Covered Preventive Care11
Covered Adult Preventive Care
Annual Physical Exam
Well-Child Care (Up to age 19;
including necessary covered
immunizations)
Preventive Well-Woman Care
Home/Office/Outpatient Care
Office Visit Copayment option12A,12B
Member Pays Out-of-Network
Deductible and Coinsurance
Deductible and Coinsurance
Deductible and Coinsurance
Specialist Copayment apply
after INN Ded
$150 copayment (waived if
admitted within 24 hours) after
INN Ded
Deductible and Coinsurance
Options
Options
In-Network Deductible, then:$35, $50, $75, $200,
$250, $300 copayment (waived if admitted in 24
hours)
In-Network Deductible then: In-Network options $0,
$200, or Specialist copayment selected
Services provided by Empire HealthChoice Assurance, Inc.,
a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
LGL 10483 (6/15) NGF
empireblue.com
Your Summary of Benefits
Empire Prismsm Deductible First PPO
For Groups with 51+ Eligible Employees
Benefit
In-Network 1
$0 after deductible
Out-of-Network 2,3
Deductible and Coinsurance
Options
$50 after deductible
Deductible and Coinsurance
In-Network Deductible then: In-Network option: $ 0
o r $100 copayment per service
Office copayment selected after deductible
$0 after deductible
$0 after deductible
Deductible and Coinsurance
Chiropractic Care8
Office copayment selected after deductible
Deductible and Coinsurance
Home Healthcare (Up to 100 visits per
calendar year)
Home Infusion Therapy
Hospice Care (Unlimited days combined
IP & OP per lifetime)
$0 after deductible
Coinsurance (no deductible)
$0 after deductible
$0 after deductible
Covered In-Network only
Covered In-Network only
Physical Therapy4,12A,12B
(Up to 30 visits per calendar year
combined in home, office or outpatient
facility)
Office copayment selected after deductible
Rider available
Other Short-Term Rehabilitative
Therapies __
Speech/Language4,12A, 12B
Occupational4 (Up to 30 visits per
calendar year combined in home,
office or outpatient facility)
Office copayment selected after deductible
Rider available
In-Network options: 30 to 120 visits in 10 visit
increments
OON Options:30 120 visits in 10 visit
increments combined with In-Network
Vision Therapy
Office copayment selected after deductible
Office copayment selected after deductible
Deductible and Coinsurance
In-Network: 36 visits OON:36 visits combined
with In-Network
Office copayment selected after deductible
$0 after deductible
Deductible and Coinsurance
Deductible and Coinsurance
Laboratory Tests, X-rays11
MRI5/MRA5, CAT Scan5, PET5 &
Nuclear Cardiology5 and
Echocardiography5
Allergy Care
Office Visit
Routine Testing
Allergy
Injections/Immunotherapy
Cardiac Rehabilitation12A, 12B (Unlimited
visits Cal/Plan year)
Second Surgical Opinion
Kidney Dialysis
Inpatient Care4,15
Inpatient Hospital (As many days as
medically necessary; semiprivate
room and board)
Surgery, Covered Surgical Assistant,
Anesthesia
Physical Therapy, Physical Medicine, or
Rehabilitation
(Up to 30 inpatient days per calendar
year)
Skilled Nursing Facility (Up to 60 days
per calendar year)
Member Pays In-Network
1) In-Network options, 30 to 120 visits in
10 visit increments.
2) OON o p ti o n s, 30 to 120 visits in 10
visit increments combined with In-Network
3)In-Network options PT/OT/ST-30 to 120
visits in 10 visit increments
4) OON options: PT/OT/ST 30 to 120
visits in 10 visit increments combined with
IN-Network
Member Pays Out-of-Network
Options
*Per admission/maximum per
Calendar/Plan year is 2.5x copayment
selected
Deductible and Coinsurance
1) $100 to $1,000 per admit* (in $100
increments after deductible)
$0 after deductible
Deductible and Coinsurance
Inpatient copayment selected after
deductible
Deductible and Coinsurance
30 to 120 days in 10 visit increments
$100/$250* copayment after deductible
Covered in-network only
90 or 120 days
2) $100 to $1,000 copayment in $100
increments per day for a maximum of 3
or 5 days per admit*
Services provided by Empire HealthChoice Assurance, Inc.,
a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
LGL 10483 (6/15) NGF
empireblue.com
Your Summary of Benefits
Empire Prismsm Deductible First PPO
For Groups with 51+ Eligible Employees
Benefit
Mental Health7
In-Network 1
Member Pays In-Network
Out-of-Network 2,3
Member Pays Out-of-Network
Outpatient Visits in Office
PCP Copayment selected after deductible
Deductible and Coinsurance
Outpatient Visits in a Facility
$0 after deductible
Deductible and Coinsurance
Inpatient Care15 (as many days as
medically necessary; semiprivate
room and board)
Inpatient copayment selected after
deductible
Deductible and Coinsurance
Alcohol/Substance Abuse7
Member Pays In-Network
Member Pays Out-of-Network
Outpatient Visits in Office
PCP Copayment selected after deductible
Deductible and Coinsurance
Outpatient Visits in a Facility
$0 after deductible
Deductible and Coinsurance
Inpatient Detoxification15 (As many days
Inpatient copayment option selected after
deductible
Deductible and Coinsurance
Inpatient copayment option selected after
deductible
Member Pays In-Network
Deductible and Coinsurance
$0 after deductible
50% coinsurance after deductible
In-Network benefits apply
Covered in-network only
Prosthetics & Orthotics5
Ambulance (Land/Air ambulance)4
50% coinsurance after deductible
Covered in-network only
$0 after deductible
In-Network benefits apply
Prescription Drugs9,10,13
Rider available
N/A
as medically necessary; semiprivate
room and board)
Inpatient Rehabilitation15
Other
Medical Supplies
Durable Medical Equipment5
Member Pays Out-of-Network
Options
Options
Options
Options
In-Network Deductible then: $50 -$500;
increments of $25
NY Prism PPO
Product RX Options.x
Reimbursement for Gym Membership:
Rider available
1) Up to $200, $300, $400, $600, $900 annual
reimbursement per contract; 50 visits required
semi-annually. Reimbursed up to half for the
first 6 months and up to half for the second 6
months.14
2) Up to $200, $300, $400, $600, $900 annual
reimbursement per contract (No visit
requirement)
Hearing Aids (Both Ears) – Once every
1, 2, or 3 years (including batteries,
supplies, maintenance, and fittings)
Vision Care
Rider available
Rider available
Rider includes OON coverage:
INN $0 after Deductible
OON: Deductible and Coinsurance
Contact Empire for more information about the
options available.
Services provided by Empire HealthChoice Assurance, Inc.,
a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
LGL 10483 (6/15) NGF
empireblue.com
Your Summary of Benefits
Empire Prismsm Deductible First PPO
For Groups with 51+ Eligible Employees
Network provider delivers care.
1
Out-of-network services (except Mental Health and Alcohol/Substance Abuse) are those from a provider that does not participate in Empire’s PPO network, or with another
Blue Cross and Blue
Shield Plan through the BlueCard® PPO Program. (This does not apply to emergency benefits.) See (7) for Mental Health and Alcohol/Substance Abuse Services.
2
Out-of-network (O-O-N) providers - those who do not participate in Empire’s PPO network, or with another Blue Cross and Blue Shield Plan through the BlueCard®
PPO Program. Out-of- network providers who do not participate with Empire or with another Blue Cross and Blue Shield Plan, may balance bill over Empire’s allowed
amount.
3
You are responsible for obtaining precertification from Empire’s Medical Management Program for these services provided in-area and out-of-area, In-Network and out-ofnetwork. Your provider may call for you, but you will be responsible for penalties applied if precertification is not obtained. For ambulatory surgery, please call the toll-free
number on your member ID card to determine exactly what outpatient services require pre-certification.
4
For services received from an Empire PPO provider, the provider must precertify In-Network services; Empire PPO providers cannot bill members beyond the
copayment, deductible, or coinsurance for covered services. Outside Empire’s network area, you must obtain precertification from Empire’s Medical Management Program
for services from In-Network BlueCard® PPO providers (with the exception of MRI, MRA, PET, CAT, Nuclear Cardiology, and Echocardiography services, which do not
require precertification for services rendered from in-network BlueCard® PPO providers outside of Empire’s network area). You are responsible for obtaining precertification
from Empire’s Medical Management Program for in-area and out-of-area out-of-network services with the exception of PET, CAT, Nuclear Cardiology, and
Echocardiography services. Your provider may call for you, but you will be responsible for penalties applied if precertification is not obtained.
5
Empire’s network provider must precertify In-Network services; Empire network providers cannot bill members beyond the copayment for covered services.
Precertification is not required for out-of-network services, nor for out-of-area In-Network BlueCard® PPO provider services.
6
You are responsible for obtaining precertification from Empire Behavioral Healthcare Manager for these services. Your provider may call for you, but you will be
responsible for penalties applied if precertification is not obtained.
7
Empire’s network provider must obtain authorization for clinical/medical necessity for In-Network services; Empire network providers cannot bill members beyond the InNetwork copayment for covered services. Authorization is not required for out-of-network services or for services rendered from In-Network BlueCard® PPO providers
outside of Empire’s network area.
8
Prescription Drug plan Option 1 listed on this Benefits Summary meet the Centers for Medicare and Medicaid Services (CMS) standard for Creditable Coverage under the
MedicareModernization Act of 2003.
9
10 To
receive a 90-day supply of prescription drugs through Empire’s Mail-Order Program, the prescription must be written specifically for a 90-day supply.
11 Preventive
care benefits not subject to copay, deductible and coinsurance; when provided In-Network include: mammography screenings, cervical cancer screenings,
colorectal cancer screenings, prostate cancer screenings, hypercholesterolemia screenings, diabetes screenings for pregnant women, bone density testing, annual
physical examinations and annual obstetric and gynecological examinations. May also include other services as required under State and Federal Law. May be subject to
age and frequency limits.
12A The
following practitioners receive the lower (primary) copay for services provided in an office: family, general & nurse practitioners, internists, pediatricians, obstetricians,
gynecologists, gerontologists, osteopaths, certified nurse midwife, preventive medicine, chiropractor & physical, occupational & speech therapists. The higher specialist copay
will apply for all other providers unless specified otherwise, and for services received in an outpatient facility for physical, occupational, speech and cardiac rehab therapies.
12B The
following practitioners receive the lower (primary) copay for services provided in an office: family, general & nurse practitioners, internists, pediatricians, obstetricians,
gynecologists, certified nurse midwife, and preventive medicine. The higher (specialist) copay will apply for all other specialists when a copay is required.
You may request, or your physician may order, the brand name drug. However, if a generic drug is available, you will be responsible for the difference in price
between Empire’s cost of the generic drug and Empire’s cost of the brand name drug, in addition to the applicable tiered Copayment amount of the generic drug, as
listed on the attached Schedule of Benefits.
13
You must submit a receipt to show that you have paid in full for the fitness club or exercise center membership. Reimbursement payments will be issued twice
annually each contract year. Covered Members are required to exercise at the club or center no less than fifty (50) visits during each six (6) month period of the contract
year. If the fitness club or exercise center does not provide proof written of member visits, a logbook will be provided to the Covered Member. The Covered Member can
request that the fitness club or exercise center representative sign the logbook to satisfy the visit requirement. See our website or your membership materials for the
mailing address and further directions on how to request reimbursement.
14
15
Network providers must obtain precertification from Empire’s Medical Management Program for these services received from an out-of-area BlueCard PPO Provider.
IMPORTANT NOTE: This is a benefits summary only and is subject to the terms, conditions and limitations and exclusions set forth in your Certificate of
Coverage, Schedule of Benefits, and any additional Riders or Contracts your group has purchased. Be sure to consult your benefit Contract or Certificate for
full details about your coverage. To the extent there is a conflict between this Summary and your benefit Contract or Certificate, the terms of the Contract or
Certificate will control. Failure to comply with Empire’s Medical Management or Behavioral Healthcare Management Program requirements could result in
benefit reductions.
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal
health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and
Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
Included are preventive care services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits.
Services provided by Empire HealthChoice Assurance, Inc.,
a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
LGL 10483 (6/15) NGF
empireblue.com