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
Empire HMO 6600 Catastrophic
Empire HMO 5600 Bronze
Empire HMO 5600 Bronze Age 29 Rider
Empire HMO 3000 Bronze Standard
Empire HMO 3000 Bronze Standard Age 29 Rider
Empire HMO 6000 Bronze
Empire HMO 6000 Bronze Age 29 Rider
Empire HMO 2250 Silver
Empire HMO 2250 Silver Age 29 Rider
Empire HMO 2450 Silver
Empire HMO 2450 Silver Age 29 Rider
Empire HMO 2000 Silver Standard
Empire HMO 2000 Silver Standard Age 29 Rider
Empire HMO 600 Gold Standard
Empire HMO 600 Gold Standard Age 29 Rider
Empire HMO 1000 Gold
Empire HMO 1000 Gold Age 29 Rider
Empire HMO 200 Platinum
Empire HMO 200 Platinum Age 29 Rider
Empire HMO 0 Platinum Standard
Empire HMO 0 Platinum Standard Age 29 Rider
Empire Blue Cross HMO 2450 Silver, a Multi-State Plan
Empire Blue Cross Blue Shield HMO 2450 Silver, a Multi-State Plan
Empire Blue Cross HMO 2450 Silver Age 29 Rider, a Multi-State Plan
Empire Blue Cross Blue Shield HMO 2450 Silver Age 29 Rider, a Multi-State Plan
Empire Blue Cross HMO 1000 Gold, a Multi State Plan
Empire Blue Cross Blue Shield HMO 1000 Gold, a Multi State Plan
Empire Blue Cross HMO 1000 Gold Age 29 Rider, a Multi State Plan
Empire Blue Cross Blue Shield HMO 1000 Gold Age 29 Rider, a Multi State Plan
Empire HMO 3000 Bronze Standard Child Only
Empire HMO 2000 Silver Standard Child Only
Empire HMO 600 Gold Standard Child Only
Empire HMO 200 Platinum Child Only
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