Your Plan: Empire Gold Healthy New York Pathway HMO 600/0%/4000 Your Network: Pathway This summary of benefits is a brief outline of coverage, designed to help y ou 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 contract of coverage. If there is a difference between this summary and the contract of coverage, the contract of cov erage will prevail. Covered Medical Benefits Overall Deductible This is an embedded plan. See notes section at the end of the document to understand how your works. Your plan may also have a separate Prescription Drug Deductible. See Retail Prescription Drug Coverage section. 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 at the end of the document for additional information regarding your out of pocket maximum. Member: $600 For Family: $1,200 Member: $4,000 For Family: $8,000 For prescription drug, all cost shares count towards your plan's annual out-of-pocket limit. Doctor Home and Office Services Preventive care In-network preventive care is not subject to, if your plan has a. Covered in full Primary care visit to treat an injury or illness Specialist care visit Prenatal care Covered in Full Post-natal care Covered in Full Page 1 of 10
Covered Medical Benefits Doctor Home and Office Services (continued) Other practitioner visits: Retail health clinic On-line visit Chiropractor services Acupuncture Other services in an office: Allergy testing Chemo/radiation therapy Hemodialysis Prescription drugs $25/ Specialist surgery Page 2 of 10
Covered Medical Benefits Diagnostic Services Lab: Freestanding Labs Office Outpatient hospital $25/ X-ray: Office Freestanding radiology center Outpatient hospital $25/ Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Office Freestanding radiology center Outpatient hospital Page 3 of 10
Covered Medical Benefits Emergency and Urgent Care Urgent care (office setting) $60 copay and 0% coinsurance after Emergency room facility services $150 copay and 0% coinsurance after Same as In Network Same as In Network Emergency room doctor and other services Ambulance (air and ground) Covered in full after $150 copay per trip after Same as In Network Same as In Network Outpatient Mental/Behavioral Health and Substance Abuse Doctor office visit Facility visit: Facility fees Doctor services Outpatient Surgery Facility fee: Freestanding surgical center Hospital $100 copay after $100 copay after Doctor services: Freestanding surgical center Hospital $100 copay after $100 copay after Page 4 of 10
Covered Medical Benefits Hospital Stay (all inpatient stays including maternity, mental / behavioral health, and substance abuse) Facility fee (for example, room & board) Doctor and other services - non surgical Doctor - surgical or maternity $1,000 copay per admission after Covered in Full $100 copay after Recovery & Rehabilitation Home health care Limited to 40 visits Rehabilitation services (for example, physical/speech/occupational therapy): Office $30 copay after Outpatient hospital Limited to 60 combined visits for Physical, Occupational and Speech Therapy per condition per lifetime. Visit limits are combined across outpatient and other professional visits. Cardiac rehabilitation Office Outpatient hospital Skilled nursing care (in a facility) Limited to 200 days for non-custodial care. Durable medical equipment & prosthetics $30 copay after $30 copay after $30 copay after $1,000 copay per admission after 20% coinsurance after Page 5 of 10
Covered Prescription Drug Benefits Prescription Drug Coverage This plan uses a Select Drug List. Drugs not on the list are not covered. Home Delivery copays are 2.5 times retail copays and select drugs are available for up to a 90 day supply. Drug Deductible (Member): None Drug Deductible (Family): None Drug tier 1 - Typically Generic $10 copay Drug tier 2 - Typically Preferred / Formulary Brand $35 copay Drug tier 3 - Typically Non-preferred/Non-formulary and Specialty Drugs $70 copay Page 6 of 10
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. Children s vision services count towards your out of pocket limit. Eye exams are covered once per 12 month period. Eyeglass lenses and Frames are covered once per 12 month period. Contact Lens benefit available only if eyeglass lens benefit is not used. For children through age 18, there is a selection of frames and contact lenses that are covered under this plan. Review the formal contract of coverage or contact your vision provider for more information. For covered services with a reimbursement amount, you will have no cost share up to that amount. All costs beyond the reimbursement amount are subject to balance billing. Children's Vision Essential Health Benefits Vision exam $25 After Deductible Frames Lenses Single Bifocal Trifocal Deductible Deductible Deductible Deductible Elective Contact Lenses Deductible Non-Elective Contact Lenses Page 7 of 10
Covered Vision Benefits Adult Vision Essential Health Benefits Vision exam Frames Lenses Single Bifocal Trifocal Elective Contact Lenses Non-Elective Contact Lenses Page 8 of 10
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. Children s dental services count towards your out of pocket limit. Children's Dental Essential Health Benefits Diagnostic and preventive Basic services Major services Medically Necessary Orthodontia services Cosmetic Orthodontia services Deductible (Medical must be met before dental copayments) Combined with Medical Out-of-Pocket Limit Combined with Medical Adult Dental Essential Health Benefits Diagnostic and preventive Basic services Major services Deductible Out-of-Pocket Limit Page 9 of 10
Notes: Your plan requires a selection of a Primary Care Physician. Your plan requires a referral from your Primary Care Physician for select covered services. All medical services subject to a coinsurance are also subject to the annual medical. This plan has an embedded which has a single and family ; the single is embedded in the family. The family can be met by any combination of amounts from any/all covered family members but one member is required to meet the single. If your plan includes a hospital stay copay and you are readmitted within 72 hours of a prior admission for the same diagnosis, your hospital stay copay for your readmission is waived. If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your emergency room facility copay is waived. Human Organ and Tissues Transplants require precertification and are covered as any other service in your summary of benefits. Your copays, coinsurance and count toward your out of pocket amount. 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 Covered external hearing aids are limited to a single purchase (including repair/replacement) once every 3 years. 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. For covered Inpatient Medical Rehabilitation, this plan covers 60 days per condition per lifetime. For additional information on this plan, please visit sbc.empireblue.com to obtain a Summary of Benefit Coverage. *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 Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Page 10 of 10