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§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 a visit will

be $25.

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