Empire Platinum Guided Access - ceaf NY

Plan Information
Company Empire Blue Cross
State NY
Metal Tier Platinum
Plan Type

Cost Sharing Benefits

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductibles and Cost Sharing In Network Out of Network
Deductible (Individual) $0 $0
Deductible (Family) $0 $0
Coinsurance $0 $0
Out of Pocket Maximum (Individual) $2,000 $0
Out of Pocket Maximum (Family) $4,000 $0
Services In Network Out of Network
Primary Care Visit $15 copay $0
Specialist Visit $35 copay $0
In Patient Hospital Services $500 copay $0
Emergency Room Services $100 copay $100 copay
Mental / Behavioral Health $15 copay $0
Imaging (CT/PET Scans, MRIs) $35 copay $0
Rehabilitative Speech Therapy $25 copay $0
Rehabilitative Occupational & Physical Therapy $25 copay $0
Preventative Care $0 $0
Laboratory Outpatient and Professional Services $35 copay $0
X-ray and Diagnostic Imaging $35 copay $0
Outpatient Facility $100 copay $0
Outpatient Surgery $100 copay $0
Prescription Drugs In Network Out of Network
Generic Rx $10 copay
Preferred Brand Rx $30 copay
Non Preferred Brand Rx $60 copay
Specialty Drugs 60

Other Plans

Other plans that are available in the state.

Plan Name
Bronze Guided Access - caat
Bronze Guided Access - cabs
Bronze Guided Access w/Dep Age 29 - cbra
Bronze Guided Access w/HAS - cacm
Bronze Guided Access w/Dep Age 29 - ccra
Bronze Guided Access w/Dep Age 29 - cara
Silver Guided Access w/HSA - cdib
Silver Guided Access - cbjw
Silver Guided Access w/HSA w/Dep Age 29 - cefa
Silver Guided Access - cbnw
Silver Guided Access w/Dep Age 29 - ceae
Silver Guided Access a Multi-State Plan
Silver Guided Access w/Dep Age 29 - ceaa
Silver guided Access w/dep age 29 a Multi State Plan
Gold Guided Access - cecb
Gold Guided Access - ccav
Gold Guided Access w/Dep Age 29 - ceea
Gold Guided Access w/Dep Age 29 - ceod
Gold Guided Access a Multi State Plan
Gold Guided Access w/dep age 29 a Mutli-State Plan
Platinum Guided Access - cazd
Platinum Guided Access - ceaf
Platinum guided Access w/Dep Age 29 - cayd
Platinum guided Access w/Dep Age 29 - ceyd
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