UUP, MC, CSEA, PBANYS and NYSCOPBA2023 Benefit Summary Comparison Chart
MY NYSHIP
Description
Empire Network Hospital Benefits
Empire PPO 001
Emblem Health
HIP HMO – 050
Office/Telehealth Co-Pay
$25.00
$5.00/$10 Specialist
Specialist Co-Pay
$25.00
$10.00
Out of Network Option
Yes
No
Out of State Coverage
Yes
No- Emergencies Only
DIAGNOSTIC SERVICES
Radiology
$40 or $50 per outpatient visit
$25.00
$5 PCP/$10 Specialist
Lab Tests
$40 or $50 per outpatient visit
$25.00
$5 PCP/$10 Specialist
Pathology
No copay
$25.00
No-Copay
EKG/EEG
$40 or $50 per outpatient visit
$25.00
$5 PCP/$10 Specialist
Radiation
No copay
No-Copay
$10.00 Specialist
Chemotherapy
No copay
No-Copay
$5 PCP/ $10 Specialist
WOMEN'S HEALTH (Copay’s may be waived if preventative)
Screenings and Maternity-Related Lab Tests
$40 or $50 per outpatient visit
$25.00
No-Copay
Mammogram
No copay
No-Copay
No-Copay
Prenatal Visits
No-Copay
No-Copay
Postnatal Visit
$40 or $50 per outpatient visit
No-Copay
No-Copay
Bone Density Tests
$25.00
No-Copay
Breastfeeding Services and Equipment
No-Copay
No-Copay
Family Planning
$25.00/per visit
$5.00 PCP/$10 Specialist
Infertility Services
$40 or $50 per outpatient visit
$25.00 (no copay if using a designated center for excellence)
$10.00 per visit
Contraceptive Drugs
No copayment for certain FDA approved oral contraception methods (including outpatient
surgical implantation and counseling)
No-Copay
Inpatient Hospital Surgery
No copay
No- Copay
No- Copay
Outpatient Surgery
$75 or $95 per visit
$50/per visit, $75 or $95 Network hospital benefit
No- Copay
Emergency Room
Applicable inpatient hospital surgery or outpatient surgery copay (see above)
$100- Waived if admitted
$75- Waived if admitted
Urgent Care
$40 or $50 per outpatient visit
$30.00
$25
Ambulance
No copay
$70 per trip
No- Copay
Outpatient Mental Health
$25.00
Unlimited
Inpatient Mental Health
No- Copay
Unlimited
Outpatient Drug/Alcohol Rehab
$25.00
$5 per visit
Inpatient Drug/Alcohol Rehab
No- Copay
No- Copay
Durable Medical Equipment
No- Copay
No- Copay
Prosthetics
No- Copay
No- Copay
Orthotics
No- Copay
No- Copay
REHAB CARE, PHYSICAL, SPEECH, & OCCUPATIONAL THERAPY
Inpatient
No copay as inpatient; $25 per visit for outpatient2
$25.00 per visit
No-Copay- max 30 day
Outpatient
$25.00
$5 PCP visit/$10 Specialist — 90 visits max
Diabetic Supplies
No- Copay
$5- 34 day supply
Diabetic Shoes
$500 annual max benefit
No-Copay when medically necessary
Hospice
No copayment, no limit
No- Copay — No limit
No-Copay - max 210 day
Skilled Nursing Facility
No copay
No-Copay up to 120 benefit days
No-Copay No limit
Prescription Drugs
$5/$30/$60
$5/$20
Mail Order Prescription Program
Yes
Yes
Hearing Aids
$1,500 per aid per year every
4 years (every 2 years for
children)Cochlear implants only
Empire PPO
Out of Network Coverage
Empire will pay 80% of “reasonable and customary” charges after the annual deductible has been satisfied. Once your deductible and out of pocket maximum have been met, Empire will pay 100% of reasonable and customary charges. The employee will be responsible for charges above the reasonable and customary rates. Annual Deductible for non-network coverage:
• Employee - $1,250
• Spouse/Domestic partner – $1,250
• All Children (combined) - $1,250
Empire PPO
In- Network Out of Pocket Limits
Once you reach the limit on your in-network benefit, you will have no additional copayments
for the
benefit calendar year.
| COVERAGE TYPE |
Prescription Drug Program |
Hospital, Medical/Surgical and Mental Health & Substance Abuse Programs, combined |
TOTAL | |
| PPO | Individual Coverage | $3,200 | $5,900 | $9,100 |
| Family Coverage | $6,400 | $11,800 | $18,200 | |
| HMO | Individual Coverage | $0 | $6,850 | $6,850 |
| Family Coverage | $0 | $13,700 | $13,700 | |
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