The Excelsior Plan - An Empire Plan Option
2017 Excelsior Plan Copayments
Participating Provider Services*
$30 Copayment - Office Visit, Office Surgery, Radiology, Diagnostic Laboratory Tests, Free-standing Cardiac Rehabilitation Center Visit, Urgent Care Visit, Convenience Care Clinic Visit
$75 Copayment - Non-hospital Outpatient Surgical Locations
$75 Copayment - Prospective Procedure Review (PPR) MRIs, MRAs, CT Scans, PET Scans, and Nuclear Medicine Tests
Chiropractic Treatment or Physical Therapy Services (Managed Physical Medicine Program)
$30 Copayment - Office Visit, Radiology, Diagnostic Laboratory Tests
Hospital Services (Hospital Program)
$30 Copayment - Outpatient Physical Therapy
$75 Copayment - Outpatient Services for Diagnostic Radiology, Diagnostic Laboratory Tests and Administration of Desferal for Cooley's Anemia in a Network Hospital or Hospital Extension Clinic
$100 Copayment - Emergency Department Visit, Outpatient Surgery
$250 Copayment - Inpatient Hospital Stay
Mental Health and Substance Abuse Program
$30 Copayment - Visit to Outpatient Substance Abuse Treatment Program
$30 Copayment - Visit to Mental Health Professional
$100 Copayment - Emergency Department Visit
$250 Copayment - Inpatient Hospital Stay
Prescription Drug Program **
Up to a 30-day supply from a participating retail pharmacy, mail service pharmacy, or specialty pharmacy
$10 Copayment - Level 1 Drug
$40 Copayment - Level 2 Drug
$70 Copayment - Level 3 Drug
31- to 90-day supply from a participating retail pharmacy
$25 Copayment - Level 1 Drug
$95 Copayment - Level 2 Drug
$180 Copayment - Level 3 Drug
31- to 90-day supply through mail service or specialty pharmacy
$20 Copayment - Level 1 Drug
$95 Copayment - Level 2 Drug
$180 Copayment - Level 3 Drug
* Note: Covered services defined as preventive under the Patient Protection and Affordable Care Act are not subject to copayment.
** Certain covered drugs do not require a copayment when using a Network Pharmacy:
- Oral chemotherapy drugs, when prescribed for the treatment of cancer
- Generic oral contraceptive drugs and devices or brand-name contraceptive drugs/devices without a generic equivalent (single-source brand-name drugs/devices)
- Tamoxifen and Raloxifene, when prescribed for the primary prevention of breast cancer
- Certain preventive adult vaccines when administered by a licensed pharmacist