Buy-Up Plan
IMPORTANT: Costs shown below are your costs. Stay In-System and use IPA physicians and non-physician providers and you only pay usual copays.The Buy-Up Plan is offered identically through Aetna and Empire - you choose.
Buy-Up Plan
Benefit
Deductible
Employee's Responsibility/ Coinsurance
Annual Out-of-Pocket Max
(Includes Deductible)
Lifetime Maximum
Dependent Children
Preventive Care
Adult Preventive Care
Annual Physical Exam
Well Child Care
(Up to Age 19 Including Covered Immunizations: 1st year = 7 exams, 2nd year = 3 exams, 3rd year = 3 exams, thereafter = 1 exam)
Well Woman Care
Home/Office/ OutPatient Care
Home/Office Visits
Emergency Room
(Initial Visit Per Occurrence)
Maternity Care
Home Healthcare
Home Infusion Therapy
Hospice Care
(Up to 210 days per Lifetime)
Outpatient Surgery, Cryosurgical Testing, Anesthesia
Chemotherapy, Radiation Therapy
Infertility Treatment
North Shore-LIJ In-System/IPA Empire or Aetna In-Network
N/A
$500 Individual/$1,000 Family
N/A
10%
N/A
$2,500 Individual/$5,000 Family
Unlimited
Unlimited
Covered until Age 26
Covered until Age 26
North Shore-LIJ IPA
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
North Shore-LIJ In-System/IPA Empire or Aetna In-Network
$20 Primary Care/ $40 Specialist Copay
Deductible & 10% Coinsurance
$100 Copay
(Waived if admitted within 24 hours)
$100 Copay
(Waived if admitted within 24 hours)
Initial $20 Primary Care/ $40 Specialist Copay; $0 after pregnancy is confirmed
Deductible & 10% Coinsurance
Covered 100% No Copay (max. 200 visits per calender year)
Covered 100% No Copay (max. 200 visits per calender year)
Covered 100% No Copay
Deductible & 10% Coinsurance
Covered 100% No Copay
Deductible & 10% Coinsurance
Covered 100% No Copay
Deductible & 10% Coinsurance
Covered 100% No Copay
Paid at 80% for up to 3 Cycles at NSUH Manhasset facility only or in the office for specific Manhasset professional Providers (Refer to listing of providers)
Deductible & 10% Coinsurance Not Covered
Out-of-Network $1,000 Individual/$2,000 Family
30% $5,000 Individual/$10,000 Family
Unlimited Covered until Age 26 Out-of-Network Deductible & 30% Coinsurance Deductible & 30% Coinsurance Deductible & 30% Coinsurance
Deductible & 30% Coinsurance
Out-of-Network Deductible & 30% Coinsurance
$100 Copay
(Waived if admitted within 24 hours)
Deductible & 30% Coinsurance
Deductible & 30% Coinsurance (max. 40 visits per calender year) Deductible & 30% Coinsurance Deductible & 30% Coinsurance
Deductible & 30% Coinsurance
Deductible & 30% Coinsurance
Not Covered
IMPORTANT: Costs shown below are your costs. Stay In-System and use IPA physicians and non-physician providers and you only pay usual copays.The Buy-Up Plan is offered identically through Aetna and Empire - you choose.
Buy-Up Plan
Home/Office/ Outpatient Care (cont'd.) North Shore-LIJ In-System/IPA Empire or Aetna In-Network
Laboratory Tests, X-Rays
Covered 100% No Copay
Deductible & 10% Coinsurance
MRI, MRA, CAT Scan, PET, & Nuclear Cardiology
Covered 100% No Copay
Deductible & 10% Coinsurance
Chiropractic Care
$40 Specialist Copay
Deductible & 10% Coinsurance
Second Surgical Opinion
$40 Specialist Copay
Deductible & 10% Coinsurance
Kidney Dialysis
Covered 100% No Copay
Deductible & 10% Coinsurance
Short Term Therapies: Physical Therapy, Speech/Language, Occupational, Developmental Delay in office or outpatient; Combined Institutional/ Professional
Covered 100% No Copay (max. 60 visits per calender year)
Deductible & 10% Coinsurance (max. 60 visits per calender year)
Inpatient Care
North Shore-LIJ In-System/IPA Empire or Aetna In-Network
Inpatient Hospital
(As many days as medically necessary; semi-private room & board)
Covered 100%
Deductible & 10% Coinsurance
Surgery, Surgical Asst., Anesthesia
Covered 100%
Deductible & 10% Coinsurance
Skilled Nursing Facility
(max. 60 days per calender year)
Covered 100%
Deductible & 10% Coinsurance
Mental Health
North Shore-LIJ In-System/IPA Empire or Aetna In-Network
Out-Patient Visits in an Office or Facility
$20 Copay
$20 Copay
Inpatient Care (As many days as medically necessary) Covered 100%
Covered 100%
Alcohol/Substance Abuse North Shore-LIJ In-System/ IPA Empire or Aetna In-Network
Out-Patient Visits in an Office or Facility
$20 copay
$20 Copay
Inpatient Detox
Covered 100%
(As many days as medically necessary)
Covered 100%
Inpatient Rehab
Covered 100%
Covered 100%
Other
North Shore-LIJ In-System
Empire or Aetna In-Network
Medical Supplies
Covered 100%
Deductible & 10% Coinsurance
Durable Medical Equipment Covered 100%
Covered 100%
Prosthetics & Orthotics
Covered 100%
Covered 100%
Ambulance
Covered 100%
Covered 100%
Out-of-Network Deductible & 30% Coinsurance Deductible & 30% Coinsurance
Deductible & 30% Coinsurance Deductible & 30% Coinsurance Deductible & 30% Coinsurance Deductible & 30% Coinsurance (max. 36 visits per calender year)
Out-of-Network Deductible & 30% Coinsurance
Deductible & 30% Coinsurance
Deductible & 30% Coinsurance Out-of-Network Deductible & 30% Coinsurance
Deductible & 30% Coinsurance Out-of-Network Deductible & 30% Coinsurance
Deductible & 30% Coinsurance
Deductible & 30% Coinsurance Out-of-Network Deductible & 30% Coinsurance Deductible & 30% Coinsurance Deductible & 30% Coinsurance Covered at In-Network Level of Benefits (100%)
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