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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