New York State Health Insurance Plan NYSHIP –CSEA

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.

Insurance Providers and Rates

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

Telehealth $25 $0 or $20 $0 $0 or $15 or $25
Emergency Room $90 $50 $100 $75
Ambulance $70 $50 $100 $50

Hospital In-patient care

Out-patient care

$0 preadmission certification required

$40 lab/radiology/urgent

$75 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 or $15 or $25 diagnostics

$25 surgery

Prescriptions

Level 1

Level 2

Level 3

Level 1

Level 2

Level 3

Level 1

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






Mail order, 90 day supply -

$10.00

$60.00

$100.00

Retail, 30 day supply -

$10.00

$30.00

$50.00






Mail order, 90 day supply -

$20.00

$60.00

$100.00

Retail, 30 day supply -

$0.00

$30.00

$50.00






Mail order, 90 day supply -

$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.

Back to top