Emergency Room Copay
- Anthem Emergency Room Copay Waiver Form
- Kaiser Emergency Room Copay
- United Healthcare Emergency Room Copay
- An emergency room visit typically is covered by health insurance. For patients covered by health insurance, out-of-pocket cost for an emergency room visit typically consists of a copay, usually $50-$150 or more, which often is waived if the patient is admitted to the hospital. Depending on the plan, costs might include coinsurance of 10% to 50%.
- Emergency Medical Care. During a medical emergency, Veterans should immediately seek care at the nearest medical facility. A medical emergency is an injury, illness or symptom so severe that without immediate treatment, you believe your life or health is in danger.
Anthem Emergency Room Copay Waiver Form
Emergency Care: $70 Copayment (The hospital outpatient copayment covers use of the facility for Emergency Room Care, including services of the attending emergency room physician and providers who administer or interpret radiological exams, laboratory tests, electrocardiogram and pathology services.).
Kaiser Emergency Room Copay
| The Empire Plan’s toll-free number is 1-877-7NYSHIP or 1-877-769-7447 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The 2019 Empire Plan Flexible Formulary is posted here. This list is limited to frequently prescribed drugs. For information about other drugs not on the list, call CVS Caremark at 1-877-7NYSHIP or 1-877-769-7447 and listen for the prompts for the Empire Plan Prescription Drug Program. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
*Non-preferred brand name drugs that have an FDA-approved generic equivalent may have additional out-of-pocket costs because of the mandatory substitution requirement.
+The Emergency Room copay is waived if the patient is admitted to the hospital. *If you fail to call, you will be responsible for paying 50% of the amount allowed or $250, whichever is less. You will also be responsible for the applicable copay or, if you used a non-par provider, deductible and/or coinsurance amounts. Preventive Care Services Benefit Preventive care services covered under federal health care reform law not subject to copayment Effective Date 10/1/11 Additional Information See https://healthcare.gov/what-are-my-preventive-care-benefits Benefit Additional preventive care services covered under federal health care reform law not subject to copayment for women (including pregnant women) Effective Date 1/1/13 Additional Information See https://healthcare.gov/what-are-my-preventive-care-benefits Benefit Additional preventive care services covered under federal health care reform law not subject to copayment for children Effective Date 1/1/13 Additional Information See https://www.healthcare.gov/what-are-my-preventive-care-benefits/#part=3 Combined Annual Deductible & Coinsurance Maximum
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| The 2018 Empire Plan Flexible Formulary is posted here.This list is limited to frequently prescribed drugs. For information about other drugs not on the list, call CVS Caremark at 1-877-7NYSHIP or 1-877-769-7447 and listen for the prompts for the Empire Plan Prescription Drug Program. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The following list contains information about the Empire Plan insurance carriers and vendors. Web sites are included, and it’s often faster than calling to find a par provider or other basic information on the website. The Empire Plan participating provider directory on the Civil Service web site enables you to search for a conveniently located provider by specialty. From the Civil Service home page, follow the prompts for NYSHIP Online, then Find a Provider. Scroll down to find the type of provider you need. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| United HealthCare 1-877-7NYSHIP or 1-877-769-7447 The Empire Plan participating provider directory on the Civil Service web site enables you to search for a conveniently located provider by specialty. From the Civil Service home page, follow the prompts for NYSHIP Online, then Find a Provider. Scroll down to find the type of provider you need, but call to verify the provider’s status. Download a non-participating provider claim form. This file can only be viewed with Adobe Acrobat Reader which can be downloaded for free at Adobe.myuhc.com provides access to claims processed by United HealthCare, the par provider directory and enrollment verification. Register by visiting the web site and clicking on the Register button. Fill in the basic information, including your Group Number which is 030500, and choose a User ID. United HealthCare will create a password and mail it to your home. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Basic Medical Provider Discount Program (Multiplan)1-877-7NYSHIP or 1-877-769-7447 When you use non-par physicians who are affiliated with Multiplan, you will receive discounts on the provider’s usual fees. You still must satisfy the annual deductible and 20% coinsurance required by Basic Medical. Multiplan has more than 200,000 providers in their network. Be sure to confirm the provider’s participation before receiving services. You can access an online list of Multiplan providers from the directory in the Civil Service web site at https://www.cs.ny.gov/employee-benefits. You can also call 1-877-7-NYSHIP and speak to a United HealthCare representative. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Centers of Excellence for Cancer (Cancer Resource Services)1-877-7NYSHIP or 1-877-769-7447 This program provides paid-in-full coverage for cancer-related expenses received through a nationwide network known as Cancer Resource Services (CRS). CRS is staffed by experienced cancer nurses who can explain treatment options and help you choose the best physician and cancer center for a specific type of cancer. The CRS network includes many of the nation’s leading cancer centers, such as Roswell Park Cancer Institute, Memorial Sloan Kettering Cancer Center and Dana-Farber Cancer Institute. Reimbursement for travel expenses is available. For more information call toll-free 1-866-936-6002 from 8 a.m. to 8 p.m., Monday – Friday, or visit the CRS web site at https://www.myoptumhealthcomplexmedical.com/gateway/public/welcome.jsp | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Empire Blue Cross and Blue Shield – hospital services 1-877-7NYSHIP or 1-877-769-7447 To use the Empire Blue Cross and Blue Shield web site, register in the Member Services window on the site. You will need your ID number, which is the first nine digits of your NY Government Employee Benefit Card. Create a personal password, which is combined with a one-time use activation key number and your log-on ID to safeguard the confidentiality of your records. You can check the status of a hospital claim, complete a coordination of benefits form. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Benefits Management Program Call United HealthCare at 1-877-7NYSHIP or 1-877-769-7447 for Prospective Procedure Review. For pre-admission certification (before a scheduled hospital admission; within 48 hours after an emergency or urgent admission; before admission or transfer to a skilled-nursing facility; before the birth of a child or as soon as a doctor confirms a pregnancy), call Empire Blue Cross Blue Shield at 1-877-7NYSHIP or 1-877-769-7447. It is your responsibility to call. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Beacon Health Options (formerly Value Options) 1-877-7NYSHIP or 1-877-769-7447 Mental health & substance abuse services. You can access an online list of Value Options providers from the directory in the Civil Service web site at https://www.cs.ny.gov/employee-benefits. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| CVS Caremark prescription drug program 1-877-7NYSHIP or 1-877-769-7447 The 2019 Empire Plan Flexible Formulary is posted here. You can order prescription refills, check order status, view prescription history, check a drug copay and print forms through the link to the CVS Caremark website from the Civil Service website. From the Civil Service home page, follow the prompts for Benefit Programs, then NYSHIP Online, then Find a Provider. Scroll down to CVS Caremark. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Managed Physical Network 1-877-7NYSHIP or 1-877-769-7447 Chiropractic care & physical therapy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Home Care Advocacy Program 1-877-7NYSHIP or 1-877-769-7447Durable medical equipment, home nursing care, infusion therapy and diabetic shoes. Diabetic supplies 1-888-306-7337. Ostomy supplies 1-800-354-4054.EPIC Hearing Service 1-866-956-5400 Program that offers nationwide access to hearing services and treatments, including hearing diagnostics and hearing aids. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Centers of Excellence for Infertility 1-877-7NYSHIP or 1-877-769-7447 Call for prior authorization of qualified procedures, regardless of provider. Call for information about all services for infertility. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
United Healthcare Emergency Room Copay
| Basic Option | |
|---|---|
| Preventive Care | Nothing for covered preventive screenings, immunizations and services |
| Physician Care | $30 for primary care1 |
| Virtual doctor visits by Teladoc® | $0 for first 2 visits |
| Urgent Care Center | $35 copay |
| Prescription Drugs | Preferred Retail Pharmacy: Tier 1 (Generics): $10 copay Tier 2 (Preferred brand): $55 copay2 Tier 3 (Non-preferred brand): 60% of our allowance ($75 minimum)2 Tier 4 (Preferred specialty): $65 copay2 Tier 5 (Non-preferred specialty): $90 copay2 Mail Service Pharmacy: Available to members with Medicare Part B primary only. Visit the Medicare page for more information. Tier 1 (Generics): $20 Tier 2 (Preferred brand): $100 copay Tier 3 (Non-preferred brand): $125 copay Specialty Pharmacy: Tier 4 (Preferred specialty): $85 copay2 Tier 5 (Non-preferred specialty): $110 copay2 |
| Maternity Care | $175 inpatient $0 outpatient |
| Hospital Care | Inpatient (Precertification is required): $175 per day; up to $875 per admission Outpatient: $100 per day per facility1 |
| Surgery | $150 in an office setting1 $200 in a non-office setting1 |
| ER (accidental injury) | $175 per day per facility |
| ER (medical emergency) | $175 per day per facility |
| Lab work (such as blood tests) | $0 copay1 |
| Diagnostic services (such as sleep studies, CT scans) | Up to $100 in an office1 Up to $150 in a hospital1 |
| Chiropractic Care | $30 per treatment; up to 20 visits per year |
| Dental Care | $30 copay per evaluation; up to 2 per year |
| Rewards Program | Earn $50 for completing the Blue Health Assessment3 Earn up to $120 for completing three eligible Online Health Coach goals3 |