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(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.
§9.5 CSEA Empire Plan Enhancements

In addition to the basic Empire Plan benefits, the Empire Plan for CSEA

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