Empire BCBS
2014 Individual
Products
Pathway Network
Key Facts:
 75% the size of the larger HMO Provider network
 75+ hospitals in the Pathway Network
 The network can be accessed through Provider Finder at
www.empireblue.com
 28 county New York Service Area for HMO products
 28 county New York Service Area for EPO products
 Under the EPO, members who reside outside of the 28 county NY service
area can use Blue Card.
2
Consolidation of rating regions
Empire’s operating area is dividing into five
rating regions for all medical products
Rates are based on the following locations:
 Albany (region 1): Albany, Columbia, Fulton,
Green, Montgomery, Rensselaer, Saratoga,
Schenectady, Schoharie, Warren and Washington
 Long Island (region 8): Nassau and Suffolk
 Mid-Hudson (region 3): Delaware, Dutchess,
Orange, Putnam, Sullivan and Ulster
 New York City (region 4): Bronx, Kings, New
York, Queens, Richmond, Rockland and Westchester
 Upstate (region 7): Clinton and Essex
3
Empire’s Individual
OFF Marketplace portfolio
(non-child only plans)
Plan Name
Deductible
Single/
Family
Office Visit
PCP
Specialist
Annual Out
of Pocket
Network
Max
Coins
Single/
Family
Pharmacy
Inpatient
Hospital
Emergency
Room
(Facility)
Urgent
Care
$200 Copay
then Ded/
Coins
$200 Copay
then Ded/
Coins
$50 Copay
then Ded/
Coins
$50 Copay
then Ded/
Coins
BRONZE
Empire Core Guided Access caat
$5,800/
$11,600
Empire Core Guided Access cabs
$4,000/
$8,000
$45
2 OV with copay;
3+ OV Ded/Coins
$35
3 OV with copay;
4+ OV Ded/Coins
Ded/ Coins
20%
$6,350/
$12,700
Ded/ Coins
$1000 Copay
then Ded/ Coins
Ded/ Coins
40%
$6,350/
$12,700
Ded/ Coins
$1,000 Copay
then Ded/
Coins
SILVER
Empire Essential Guided
Access w/HSA - cbib
Empire Essential Guided
Access - cbjw
Ded then
Ded then $200 Ded then $50
$1,000 Copay &
Copay & Coins Copay & Coins
Coins
$1,000 Copay $200 Copay
$50 Copay
then Ded/
then Ded/
then Ded/
Coins
Coins
Coins
$2,450/
$4,900
Deductible/ Coinsurance
10%
$6,350/
$12,700
Ded/ Coins
$2,250/
$4,500
$30 Copay
(No Ded)
25%
$5800/
$11,600
Ded/ Coins
$1,000/
$2,000
$30 Copay
(No Ded)
10%
$6,250/
$12,500
Tier 1 - $15
Tier 2 - $40
Tier 3 Ded/Coins
$1,000 Copay
then Ded/ Coins
$200 Copay
then Ded/
Coins
$50 Copay
then Ded/
Coins
$200/
$400
$25 Copay
(No Ded)
5%
$3,400/
$6,800
Tier 1 - $15
Tier 2 - $40
Tier 3 Ded/Coins
$500 Copay
then Ded/
Coins
$200 Copay
then Ded/
Coins
$50 Copay
then Ded/
Coins
Ded/ Coins
GOLD
Empire Preferred Guided
Access - cecb
Ded/ Coins
PLATINUM
Empire Premier Guided
Access - cazd
Ded/ Coins
The above is a summary. See the Certificate of Coverage with the Schedule of Benefits and any riders associated with the plan for complete coverage details and related terms and conditions.
4
Individual Enrollment
To be eligible, an individual must live in one of the 28 counties where
Empire is licensed to sell
Open Enrollment:
▪ Plans can be purchased once a year through an open enrollment period
• 1/1/14 effective date – open enrollment from 10/1 to 12/15
• Post 1/1/14 effective date – open enrollment from 12/16/13 to 3/31/14
Effective date assignment rules will be the same for ON and OFF the
Individual Marketplace
▪ If application received 1st – 15th, effective 1st of next month
▪ If application received 16th – EOM, effective 1st of following month
Exception: Newborns and adopted children can be added or enrolled in a plan
as of the date of birth or placement as long as we are advised within 60 days.
5
Empire BCBS 2014 Individual Rates
Plan Name
NYC Single Rate
Bronze
Core Guided Access (caat)
$359.87
Core Guided Access (cabs)
$367.44
Silver
Essential Guided Access (cbjw)
$427.33
Essential Guided Access w/ HSA (cdib)
$417.57
Gold
Preferred Guided Access (cecb)
$518.56
Platinum
Premier Guided Access (cazd)
$615.61
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