Empire Blue Cross Blue Shield
Your Plan: Empire Gold Blue Priority EPO 35/10%/7000
Your Network: Blue Priority
This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and
every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review
the formal Certificate of Insurance or Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of
Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail.
Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
Overall Deductible
See notes section to understand how your deductible works. Your plan may also have
a separate Prescription Drug Deductible. See Prescription Drug Coverage section.
$0
$0
Out-of-Pocket Limit
When you meet your out-of-pocket limit, you will no longer have to pay cost-shares
during the remainder of your benefit period. See notes section for additional
information regarding your out of pocket maximum.
$7,000 person /
$14,000 family
$0
Preventive care/screening/immunization
In-network preventive care is not subject to deductible, if your plan has a
deductible.
No charge
Not covered
Primary care visit to treat an injury or illness
$35 copay per visit
deductible does not
apply
Not covered
Specialist care visit
$50 copay per visit
deductible does not
apply
Not covered
Prenatal Care
Covered at 100% per pregnancy
No charge
Not covered
Post-natal Care
Covered at 100% per pregnancy
No charge
Not covered
Covered Medical Benefits
Doctor Home and Office Services
Hospital clinics are not covered.
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Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
$35 copay per visit
deductible does not
apply
Not covered
On-line Visit
$35 copay per visit
deductible does not
apply
Not covered
Chiropractor services
$50 copay per visit
deductible does not
apply
Not covered
Acupuncture
$50 copay per visit
deductible does not
apply
Not covered
$50 copay per visit
deductible does not
apply
Not covered
Chemo/radiation therapy
$50 copay per visit
and then 10%
coinsurance
deductible does not
apply
Not covered
Hemodialysis
Coverage for Non-Network Providers is limited to 10 visits per benefit
period.
$50 copay per visit
and then 10%
coinsurance
deductible does not
apply
Not covered
Prescription drugs
For the drugs itself dispensed in the office thru infusion/injection
$50 copay per visit
and then 10%
coinsurance
deductible does not
apply
Not covered
Covered Medical Benefits
Other practitioner visits:
Retail health clinic
Other services in an office:
Allergy testing
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Diagnostic Services
Lab:
Office
$50 copay per visit
and then 10%
coinsurance
deductible does not
apply
Not covered
Freestanding Lab
No charge
Not covered
Outpatient Hospital
$500 copay per
admission
deductible does not
apply
Not covered
Office
$50 copay per visit
and then 10%
coinsurance
deductible does not
apply
Not covered
Freestanding Radiology Center
$500 copay per
admission
deductible does not
apply
Not covered
Outpatient Hospital
$500 copay per
admission
deductible does not
apply
Not covered
Office
$50 copay per visit
and then 10%
coinsurance
deductible does not
apply
Not covered
Freestanding Radiology Center
$500 copay per
admission
deductible does not
apply
Not covered
Outpatient Hospital
$500 copay per visit
Not covered
X-ray:
Advanced diagnostic imaging (for example, MRI/PET/CAT
scans):
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and then 10%
coinsurance
deductible does not
apply
Emergency and Urgent Care
Emergency room facility services
Emergency room member cost share (except deductible if applicable) is waived if
admitted.
$350 copay per visit
deductible does not
apply
$350 copay per visit
deductible does not
apply
Emergency room doctor and other services
No charge
No charge
Ambulance (air and ground)
$350 copay per trip
deductible does not
apply
$350 copay per trip
deductible does not
apply
Urgent Care (office setting)
$100 copay per visit
deductible does not
apply
$100 copay per visit
deductible does not
apply
$50 copay per visit
deductible does not
apply
Not covered
$500 copay per
admission
deductible does not
apply
Not covered
Hospital
$500 copay per
admission
deductible does not
apply
Not covered
Freestanding Surgical Center
$500 copay per
admission
deductible does not
apply
Not covered
Outpatient Mental/Behavioral Health and Substance Abuse
Doctor office visit
Facility visit:
Facility fees
Outpatient Surgery
Facility fees:
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Doctor and other services
10% coinsurance
after deductible is
met
Not covered
Facility fees (for example, room & board)
For covered Inpatient Medical Rehabilitation, this plan covers 60 days per Plan
Year. A separate 60 days per Plan Year is covered for Inpatient Habilitation.
Copay is waived for readmission within 90 days of a previous discharge.
$500 copay per day
deductible does not
apply
Not covered
Doctor and other services
10% coinsurance
after deductible is
met
Not covered
$50 copay per visit
after deductible is
met
Not covered
Office
Coverage for physical therapy, occupational therapy and speech therapy
combined In-Network Providers is limited to 60 visits per benefit period.
$50 copay per visit
deductible does not
apply
Not covered
Outpatient hospital
Coverage for physical therapy, occupational therapy and speech therapy
combined In-Network Providers is limited to 60 visits per benefit period.
$500 copay per visit
and then 10%
coinsurance
deductible does not
apply
Not covered
Habilitation services
Habilitation therapy for outpatient Physical, Speech, Occupational
therapies have a separate 60 day limit from outpatient rehabilitation
therapies
$50 copay per visit
deductible does not
apply
Not covered
Hospital Stay (all inpatient stays including maternity, mental /
behavioral health, and substance abuse)
Recovery & Rehabilitation
Home health care
Coverage for In-Network Providers is limited to 40 visits per benefit period.
Rehabilitation services (for example,
physical/speech/occupational therapy):
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Cardiac rehabilitation
Office
$50 copay per visit
deductible does not
apply
Not covered
Outpatient hospital
$500 copay per visit
and then 10%
coinsurance
deductible does not
apply
Not covered
Skilled nursing care (in a facility)
Coverage is limited to 200 days per benefit period. Copay is waived for readmission
within 90 days of a previous discharge.
$500 copay per day
deductible does not
apply
Not covered
Hospice
10% coinsurance
after deductible is
met
Not covered
Durable Medical Equipment
Covered external hearing aids are limited to a single purchase (including/repair
replacement) once every 3 years.
10% coinsurance
after deductible is
met
Not covered
Prosthetic Devices
Coverage for In-Network Provider is limited to 1 unit per limb, per lifetime.
10% coinsurance
after deductible is
met
Not covered
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Covered Prescription Drug Benefits
Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
Pharmacy Deductible
$0
$0
Pharmacy Out of Pocket
$0
$0
Tier 1 - Typically Generic
Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply
(home delivery program). No coverage for non-formulary drugs.
$10 copay per
prescription after
deductible is met
(retail only) and $25
copay per
prescription after
deductible is met
(home delivery only)
Not covered
Tier 2 - Typically Preferred/Formulary Brand
Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply
(home delivery program). No coverage for non-formulary drugs. If you select a
brand name drug when a generic drug is available, additional cost sharing
amounts may apply.
$35 copay per
prescription after
deductible is met
(retail only) and
$105 copay per
prescription after
deductible is met
(home delivery only)
Not covered
Tier 3 - Typically Non-preferred/Non-formulary and Specialty
Drugs
Covers up to a 30 day supply (retail pharmacy). Covers up to a 30 day supply
for Specialty Drugs (home delivery program). No coverage for non-formulary
drugs. If you select a brand name drug when a generic drug is available,
additional cost sharing amounts may apply.
$75 copay per
prescription after
deductible is met
(retail only) and
$225 copay per
prescription after
deductible is met
(home delivery only)
Not covered
Tier 4 - Typically Specialty Drugs
Not Applicable
Not Applicable
Prescription Drug Coverage
BCBS National Drug List
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Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
Not Applicable
Not Applicable
Vision exam
Coverage for In-Network Providers is limited to 1 exam per benefit period.
No charge
Not covered
Frames
Coverage for In-Network Providers is limited to 1 unit per benefit period.
No charge
Not covered
Lenses
Coverage for In-Network Providers is limited to 1 unit per benefit period.
No charge
Not covered
Elective contact lenses
Coverage for In-Network Providers is limited to 1 unit per benefit period.
No charge
Not covered
Not Applicable
Not Applicable
Vision exam
Coverage for In-Network Providers is limited to 1 exam per benefit period.
$20 copay per visit
Not covered
Frames
Coverage is limited to 1 unit every 2 years. Coverage is limited to $130
maximum benefit per occurrence. Apply to In-Network Providers.
No charge
Not covered
Lenses
Coverage for Eye Glasses or Contact Lens In-Network Providers is limited to 1
unit every 2 years.
$20 copay per unit
Not covered
Elective contact lenses
Coverage is limited to $80 maximum benefit per occurrence. Coverage for Eye
Glasses or Contact Lens is limited to 1 unit every 2 years.
No charge
Not covered
Covered Vision Benefits
This is a brief outline of your vision coverage. Not all cost shares for covered services
are shown below. For a full list, including benefits, exclusions and limitations, see the
combined Evidence of Coverage/Disclosure form/Certificate. If there is a difference
between this summary and either Evidence of Coverage/Disclosure form/Certificate,
the Evidence of Coverage/Disclosure form/Certificate will prevail.
Only children's vision services count towards your out of pocket limit.
Children's Vision Essential Health Benefits
Child Vision Deductible
Non-Elective Contact Lenses
Adult Vision
Adult Vision Deductible
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Covered Vision Benefits
Non-Elective Contact Lenses
Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
No charge
Not covered
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Cost if you use an
In-Network
Provider
Cost if you use a
Non-Network
Provider
No charge after
deductible is met
Not covered
Basic services
No charge after
deductible is met
Not covered
Major services
No charge after
deductible is met
Not covered
Medical Necessary Orthodontia services
50% coinsurance
after deductible is
met
Not covered
Cosmetic Orthodontia services
Not covered
Not covered
Deductible
Combined with
medical deductible
Not covered
Diagnostic and preventive
Not covered
Not covered
Basic services
Not covered
Not covered
Major services
Not covered
Not covered
Deductible
Not Applicable
Not Applicable
Annual maximum
Not Applicable
Not Applicable
Covered Dental Benefits
This is a brief outline of your dental coverage. Not all cost shares for covered services
are shown below. For a full list, including benefits, exclusions and limitations, see the
combined Evidence of Coverage/Disclosure form/Certificate. If there is a difference
between this summary and either Evidence of Coverage/Disclosure form/Certificate,
the Evidence of Coverage/Disclosure form/Certificate will prevail.
Only children's dental services count towards your out of pocket limit.
Children's Dental Essential Health Benefits
Diagnostic and preventive
Coverage for In-Network Providers is limited to 2 visits per12months.
Adult Dental
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Notes:
• The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family
member will be applied to the individual deductible and individual out-of-pocket maximum; in addition,
amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one
member will pay more than the individual deductible and individual out-of-pocket maximum.
• For additional information on this plan, please visit sbc.anthem.com to obtain a "Summary of Benefit
Coverage".
• Human Organ and Tissues Transplants require precertification and are covered as any other service in your
summary of benefits.
• Your copays, coinsurance and deductible count toward your out of pocket amount.
• Vision services are not subject to the annual deductible.
• You may obtain Urgent Care from a Non-Participating Urgent Care Center or Physician outside our Service
Area. We do not cover Urgent Care from Non-Participating Urgent Care Centers or Physicians in Our Service
Area without a preauthorization
• Speech and Physical Therapy are only covered following a hospital stay or surgery
• Empire's Service Area: Albany, Bronx, Clinton, Columbia, Delaware, Dutchess, Essex, Fulton, Green, Kings,
Montgomery, Nassau, New York, Orange, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga,
Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington and Westchester.
• Services provided by Empire HealthChoice HMO, Inc and/or Empire HealthChoice Assurance, Inc., licensees
of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
• The prescription drug plan listed on this summary meets the Centers for Medicare and Medicaid Services
(CMS) standard for Creditable Coverage under the Medicare Modernization Act of 2003.
• This plan provides a Gym Reimbursement benefit up to $200 per 6 month period; up to an additional $100 per
6 month period for Spouse.
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of
independent Blue Cross and Blue Shield plans.
Questions:(855) 330-1105 or visit us at www.empireblue.com
NY/S/F/Empire Gold Blue Priority EPO 35/10%/700/2KKE/NA/01-17
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