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network level of benefits.

§9.3 Empire Plan Medical/Surgical

The Empire Plan shall include medical/surgical coverage through use of
participating providers who will accept the Plan's schedule of allowances

as payment in full for covered services. Except as noted below, benefits
will be paid directly to the provider at 100% of the Plan's schedule not

subject to deductible, coinsurance, or annual/lifetime maximums.
Preventive care services as established by the 2010 Federal Patient

Protection and Affordable Care Act will be covered in full when an
individual utilizes a Participating Provider.

(a) Office visit charges by participating providers will be subject to a $20
copayment per covered individual. Effective January 1, 2019, the

copayment for office visit charges by participating providers will be $25.
Office visit charges by participating providers for well childcare, including

routine pediatric immunizations, will be excluded from the office visit
copayments.

(b) Charges by participating providers for professional services for
allergen immunotherapy in the prescribing physician's office or institution

will be excluded from the office visit copayment.
(c) All covered outpatient surgery procedures performed by a

participating provider during a visit will be subject to a $20 copayment per
covered individual. Effective January 1, 2019, the copayment for covered

outpatient surgery procedures performed by a participating provider during
a visit will be $25.

(d) In the event that there is both an office visit charge and an office

surgery charge by a participating provider in any single visit, the covered
individual will be subject to a single copayment.
(e) All covered diagnostic/laboratory services performed by a

participating provider during a visit will be subject to a $20 copayment per

covered individual. Effective January 1, 2019, the copayment for covered
diagnostic/laboratory services performed by a participating provider will

be $25.
(f) All covered outpatient radiology services performed by a participating

provider during a visit will be subject to a $20 copayment per covered
individual. Effective January 1, 2019, the copayment for covered

outpatient radiology services performed by a participating provider during

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