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a visit will be $25.

(g) Outpatient radiology services and diagnostic/laboratory services

rendered during a single visit by the same participating provider will be
subject to a single copayment.

(h) Chronic care services for chemotherapy, radiation therapy, or
hemodialysis will be excluded from the office visit copayment.

(i) The office visit, surgery, outpatient radiology, and
diagnostic/laboratory copayments may be applied against the annual

coinsurance maximum but they will not be considered covered expenses
for basic medical payment.

(j) All covered outpatient surgery performed at a participating
freestanding ambulatory surgery center will be subject to a $30 copayment.

Effective January 1, 2019, the copayment for covered outpatient surgery
performed at a participating freestanding ambulatory surgery center will be

$50. Covered services shall include anesthesiology, radiology and
laboratory tests performed on the same day of surgery.

(k) Licensed and certified nurse practitioners and convenience care
clinics (also commonly referred to as “minute clinics” or “retail clinics”)

will be available as participating providers in the Empire Plan subject to
the applicable participating provider copayment(s).

(l) All covered urgent care centers participating with the medical carrier
will be subject to a $20 copayment. Effective January 1, 2019, the copay

for urgent care centers participating with the medical carrier will be $30.
§9.4 Empire Plan Basic Medical

The Empire Plan shall also include basic medical coverage to provide

benefits when non-participating providers are used. These benefits will be
paid directly to enrollees according to reasonable and customary charges
and will be subject to deductible, coinsurance, and calendar year and

lifetime maximums.

(a) The Empire Plan participating provider schedule of allowances and
the basic medical reasonable and customary levels will be at least equal to

those levels in effect on March 31, 2016.
(b) An annual evaluation and adjustment of basic medical reasonable and

customary charges will be performed according to the guidelines
established by the basic medical plan insurer.

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