2022
This is a summary of some of the most popular types of medical services individuals seek. You may want to obtain costs for other types of services you might utilize. This is simply a guide designed to assist you in choosing a plan for yourself and your dependents, if applicable. Pre-authorization is required for hospitalizations and for some services/prescriptions. Additional costs may apply, as well.
Review all available information about all plans and contact the carrier(s) for more information before making a decision.
|
Empire Plan (1-877-769-7447) |
CDPHP (1-800-777-2273) |
HMO Blue (1-800-722-7884) |
MVP (1-888-687-6277) |
|
|---|---|---|---|---|
| Type of plan | PPO | HMO | HMO | HMO |
| Primary care physician required | No | Yes | Yes | Yes |
| Combined deductible for out of network services; then 80% / 20% coverage | $1250^ | N/A | N/A | N/A |
| Office Visit |
$25 $30 urgent care $25 specialty office |
$20 $25 urgent care $20 specialty office |
$25 $35 urgent care $40 specialty office |
$15 adults $0 sick child (age 0 –25) $15 urgent care facility $25 specialty office Emergency room |
| Telehealth | $25 | $0 or $20 | $0 | $0 or $15 or $25 |
| Emergency Room | $100 | $50 | $100 | $75 |
| Ambulance | $70 | $50 | $100 | $50 |
|
Hospital In-patient care Out-patient care |
$0 preadmission certification required $50 lab/radiology/urgent $95 surgery |
$0 $20 diagnostics $75 surgery |
$0 for facility and lesser of $200 or 20% for doctor $0 or $25 or $40 diagnostics $40 for doctor in hospital^^ $50 surgery facility |
$0 $0 or $15 or $25 diagnostics $25 surgery |
|
Prescriptions Level 1 Level 2 Level 3 Level 2 Level 3 Level 2 Level 3 |
Retail, 30 day supply - $5.00 $30.00 $60.00
Retail, 90 day supply - $10.00 $60.00 $120.00
Mail order, 90 day supply - $5.00 $55.00 $110.00 |
Retail, 30 day supply - $5.00 $30.00 $50.00
$10.00 $60.00 $100.00 |
Retail, 30 day supply - $10.00 $30.00 $50.00
$20.00 $60.00 $100.00 |
Retail, 30 day supply - $0.00 $30.00 $50.00
$0.00 $75.00 $125.00 |
| Dependent children | Covered through the last day of the month in which they turn age 26 | Covered through the last day of the month in which they turn age 26 | Covered through the last day of the month in which they turn age 26 | Covered through the last day of the month in which they turn age 26 |
|
Bi-weekly cost* Individual plan Family plan |
All of New York State $50.89 $67.85 $219.75 $ 261.73 |
Otsego area** $43.60 $58.14 $182.66 $217.79 |
Otsego area** $47.09 $62.79 $209.84 $249.64 |
Otsego area** $53.90 $70.39 $197.41 $235.91 |
^$625 for employees in SG-6 and below.
^^In physician’s office, $50 copayment or 20% coinsurance, whichever is less.
*Lower rates apply for employees in SG-9 and below. Higher rates apply for employees in SG-10 and above.
**If you live in a county other than Otsego, inquire about other available rates/HMOs.