- Either you or your ambulance company may request prior authorization for these scheduled, non-emergency ambulance services. If your prior authorization request isn’t approved and you continue getting these services, Medicare will deny the claim and the ambulance company may bill you for all charges. For more information, call us at 1-800.
- For patients with health insurance, out-of-pocket costs for ambulance service typically consist of a copay of $15 to $100 or more or coinsurance of 10% to 50%.
Covered Services
Learn more about what we cover -including health, dental, and pharmacy.
Ambulance copay (when medically necessary) In network $100. Out of network Not covered. Preferred generic pharmacy copay. Preferred generic pharmacy copay. This is what you'll pay when you buy a commonly prescribed generic version of a brand-name drug. $50 co-pay /visit Not Covered None. 50% co-insurance Not Covered Preauth required for Residential Treatment, with the exception of some scenarios. $75 co-pay /visit Not Covered Abortions (exempt and non-exempt) are covered under your medical benefit, Limits apply. Cost share may apply for initial visit to determine pregnancy. Transportation as well as air ambulance transportation when appropriate for the patient’s condition. + Under both – Standard and Basic - Options, members pay a $100 copayment per day for ground ambulance services performed by both Preferred and Non-preferred ambulance providers. + For air or sea ambulance transportation.
TRICARE covers:- Treat and release: When an ambulance treats you, but doesn’t take you to the hospital.
- Outpatient services. This includes:
- Emergency transfers to or from your home, accident scene, or other location to a hospital.
- Inpatient services. This includes:
- Ambulance transfers from a hospital-based emergency roomThe hospital department that provides emergency services to patients who need immediate medical attention. to a hospital more capable of providing the required care.
- Transfers between a hospital or skilled nursing facility and another hospital-based or freestanding outpatient therapeutic or diagnostic department/facility.
- Air ambulance or boat ambulance transport when a land vehicle can't get to you, or when great distance or other obstacles are involved in transporting you to the nearest hospital with appropriate facilities. Your medical condition must require a speedy admission or indicate you can't be transferred by other means. The costs may differ from land ambulance.
- Joint response situations: When an ambulance crew needs the help of a paramedic or intermediate EMT to give you advanced life support services
Payment of services and supplies provided by ambulance personnel at an accident scene may be allowed when your condition requires transfer to an inpatient acute setting and medical services and/or supplies are provided solely to stabilize your condition while awaiting the arrival of a more urgent means of transfer; e.g., air ambulance services.
TRICARE doesn't cover:
- Ambulance service you use instead of taxi service when your condition would have permitted use of regular private transportation
- Your transport or transfer to be closer to home, family, friends, or personal physician
- Medicabs or ambicabs that transport you to and from medical appointments
This list of covered services is not all inclusive. TRICARE covers services that are medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition. and considered proven. There are special rules or limits on certain services, and some services are excluded.
Last Updated 10/28/2020
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This online publication has been updated to include the Amendments through January 1, 2014. For details such as the effective dates of amendments, see your group-specific amendments in the Publications & Forms section of this site.
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Services by Empire Plan Participating Providers
Office Visit - $20
Office Surgery - $20
(If there are both an Office Visit charge and an Office Surgery charge by a Participating Provider in a single visit, only one copayment will apply, in addition to any copayment due for Radiology/Laboratory Tests.)
Radiology, Single or Series; Diagnostic Laboratory Tests - $20
(If Outpatient Radiology and Outpatient Diagnostic Laboratory Tests are charged by a Participating Provider during a single visit, only one copayment will apply, in addition to any copayment due for Office Visit/Office Surgery.)
Routine Mammography Screening: - No copayment
Adult Immunizations for Herpes Zoster (Shingles) immunization for enrollees age 55 and over but under age 60 - Paid-in-full benefit for covered adult immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers of Disease Control and Prevention when received from a participating provider.
Allergen Immunotherapy - No copayment
Well-Child Office Visit, including Routine Pediatric Immunizations - No copayment
Prenatal Visits and Six-Week Check-Up after Delivery - No copayment
Chemotherapy, Radiation Therapy, Dialysis - No copayment
Authorized care at Infertility Center of Excellence - No copayment
Hospital-based Cardiac Rehabilitation Center - No copayment
Anesthesiology, Radiology, Pathology in connection with inpatient or outpatient network hospital services - No copayment
Free-standing Cardiac Rehabilitation Center visit - $20 Copayment
Urgent Care Center - $20 Copayment
Convenience Care Clinic Visit - $20 Copayment
Contraceptive Drugs and Devices when dispensed in a doctor's office - $20 Copayment*
(in addition to any copayment(s) due for Office Visit/Office Surgery and Radiology/Laboratory Tests)
*Copayment waived for preventive services under the federal Patient Protection and Affordable Care Act (PPACA). See NYSHIP Online for details. Diagnostic services require Plan copayment or coinsurance.
Outpatient Surgical Locations (including Anesthesiology and same-day pre-operative testing done at the center) - $30
Medically appropriate professional ambulance transportation - $35 Charge
Chiropractic Treatment or Physical Therapy Services by Managed Physical Network (MPN) Providers
You pay only your copayment when you choose MPN network providers for covered services. To find an MPN network provider, ask the provider directly, or call UnitedHealthcare at 1-877-7-NYSHIP (1-877-769-7447) toll free. Internet: https://www.cs.ny.gov.
Office Visit - $20 Copayment
Radiology; Diagnostic Laboratory Tests - $20 Copayment (If Radiology and Laboratory Tests are charged by an MPN network provider during a single visit, only one copayment will apply, in addition to any copayment due for Office Visit.)
Hospital Outpatient Department Services
Emergency Care - $60 Copayment*
(The $60 hospital outpatient copayment covers use of the facility for Emergency Room Care, including services of the attending emergency room physician and providers who administer or interpret radiological exams, laboratory tests, electrocardiogram and pathology services.)
Network Hospital Outpatient Department Services
Surgery - $40 Copayment*
Diagnostic Laboratory Tests - $30 Copayment*
Diagnostic Radiology (including mammography, according to guidelines) - $30 Copayment*
Administration of Desferal for Cooley's Anemia - $30 Copayment*
Physical Therapy (following related surgery or hospitalization) - $20 Copayment
Chemotherapy, Radiation Therapy, Dialysis - No copayment
Pre-Admission Testing/Pre-Surgical Testing prior to inpatient admission - No copayment
*Only one copayment ($40 copayment if surgery is included; $30 copayment if diagnostic outpatient services only) per visit will apply for all covered hospital outpatient services rendered during that visit. The copayment covers the outpatient facility. Provider services may be billed separately. You will not have to pay the facility copayment if you are treated in the outpatient department of a hospital and it becomes necessary for the hospital to admit you, at that time, as an inpatient.
Be sure to follow Benefits Management Program requirements for hospital admissions, skilled nursing facility admission and Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA). Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine tests.
Mental Health and Substance Abuse Services by Network Providers When You Are Referred by Beacon Health Options
Call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) toll free before beginning treatment.
Visit to Outpatient Substance Abuse Treatment Program - $20 Copayment
Visit to Mental Health Professional - $20 Copayment
Emergency Room Care - $60 Copayment
Psychiatric Second Opinion when Pre-Certified - No copayment
Mental Health Crisis Intervention (three visits) - No copayment
Inpatient - No copayment
Empire Plan Prescription Drugs*
Note: Medicare-primary enrollees or dependents should refer to the Empire Plan Medicare Rx Evidence of Coverage for prescription copayment amounts
(Only one copayment applies for up to a 90-day supply.)
Up to a 30-day supply from a network pharmacy or through the Mail Service Pharmacy or the Designated Specialty Pharmacy
$5 Copayment – Generic Drugs or Level 1 Drugs
$25 Copayment – Preferred Brand-name Drugs, Compound Drugs or Level 2 Drugs
$45 Copayment – Non-preferred Brand-name Drugs or Level 3 Drugs**
31 to 90-day supply from a network pharmacy
$10 Copayment – Generic Drugs or Level 1 Drugs
$50 Copayment – Preferred Brand-name Drugs, Compound Drugs or Level 2 Drugs
$90 Copayment – Non-preferred Brand-name Drugs or Level 3 Drugs**
31 to 90-day supply through the Mail Service Pharmacy
$5 Copayment – Generic Drugs or Level 1 Drugs
$50 Copayment – Preferred Brand-name Drugs, Compound Drugs or Level 2 Drugs
$90 Copayment – Non-preferred Brand-name Drugs or Level 3 Drugs**
Ambulance Copay
*Note: Oral chemotherapy drugs for the treatment of cancer do not require a copayment and covered services defined as preventive under the Patient Protection and Affordable Care Act are not subject to copayment.
**If you choose to purchase a brand-name drug that has a generic equivalent, you pay the non-preferred brand-name copayment plus the difference in cost between the brand-name drug and its generic equivalent (with some exceptions), not to exceed the full cost of the drug.