new mental health/substance abuse insurer and administrator · caduet, coreg cr, doryx,...

NEW YORK STATE HEALTH INSURANCE PROGRAM (NYSHIP)FOR NEW YORK STATE POLICE TROOPERSREPRESENTED BY PBAAnd for their enrolled Dependentsand for COBRA Enrollees with their Empire Plan Benefits

J A N U A R Y 2 0 0 9

Read this Report forimportant information aboutbenefit changes.

P L A NREPORT

Effective January 1, 2009,UnitedHealthcare Insurance Company of New York (UHICNY) insures andOptumHealth Behavioral Solutions(OptumHealth) administers The Empire Plan Mental Health andSubstance Abuse (MHSA) Program. The former insurer/administrator, GHI/ValueOptions, will assist with thetransition. Although your benefits are not changing, there may be differences in the provider network.OptumHealth has a large nationalprovider network and also is activelyrecruiting additional providers whocurrently treat a high volume of EmpirePlan enrollees. To check if your provideris in the OptumHealth network, you can

call 1-877-7-NYSHIP (1-877-769-7447)and select the 2009 MHSA option forOptumHealth. You may also visitwww.cs.state.ny.us to search theOptumHealth provider network online.At the home page click on “BenefitPrograms” and follow the instructionsto access NYSHIP Online. Select “Find a Provider” and scroll down toOptumHealth. The network lists will be updated regularly as providers areadded. If your provider is not currentlyin the OptumHealth network, you maynominate your provider by calling theNYSHIP toll free number and selectingthe 2009 MHSA option.

I n T h i s R e p o r t

1&4 Flexible Formulary 1-3 Mental Health/Substance

Abuse Program6 Benefit Changes

NYSHIP GeneralInformation Book and Empire Plan Cer tificateAmendments

9 Reminders10 Par ticipating Provider

Directories; Annual Notice11 Empire Plan Carriers

and Programs 12 Dependent Eligibility; Waiver

of Out-of-Pocket Costs

SPECIALSECTION

SAVE THISREPORT

New Insurer and Administratorcontinued on page 2

Effective January 1, 2009, your benefitsunder The Empire Plan PrescriptionDrug Program are based on a flexibleformulary. The 2009 Empire PlanFlexible Formulary drug list providesenrollees and the Plan with the bestvalue in prescription drug spending.This is accomplished by:• excluding coverage for a small

number of drugs if a therapeuticequivalent or over-the-counter drug is available.

• assigning a slightly higher copayment,than generic drugs, for preferredbrand-name drugs that provide thebest value to The Empire Plan and

• allocating the highest copayment to non-preferred brand-name drugsthat provide little, if any, clinicaladvantage over existing generic orpreferred brand-name drugs.

Flexible Formulary continued on page 4

New Mental Health/Substance Abuse Insurer and Administrator

Empire Plan Adopts Flexible Formulary for 2009

70940_PBA_T_Report.qxp 3/24/09 3:57 PM

EPR-PBA-T-09-012

Transition BenefitsTo help ensure that Empire Planenrollees in outpatient treatment haveaccess to network benefits throughoutthis transition, a 90-day transition ofcare benefit is available for care received through March 31, 2009. The transition of care benefit alsoapplies to alternate levels of careincluding partial hospitalization,intensive outpatient treatment andgroup home. If you or your dependentreceived outpatient care under theMHSA Program on or after July 1, 2008,you are eligible for network benefitswith the same practitioner(s) through March 31, 2009 regardless of whetherthe provider is in the OptumHealthnetwork. If you have received MHSAservices from a MHSA practitioner sinceJuly 1, 2008, you should have received a letter prior to the end of the year withadditional information about this changeand how to get more information abouttransition of care benefits.If you or your dependents were receivingcare at a 24-hour facility or program forinpatient or residential treatment onDecember 31, 2008 and remainedconfined on or after January 1, 2009, the care will continue to be managedand paid for by ValueOptions/GHI untilyou are discharged to a lower level oftreatment.

Empire Plan Toll-Free NumberIf you need services or if you have any questions about transition, call 1-877-7-NYSHIP and select the 2009MHSA option. When calling the toll free NYSHIPnumber, please listen carefully as optionswill change. You will be able to reachboth OptumHealth and ValueOptions fora period of time. Clinical Referral Lineservices will be provided by OptumHealthand continue to be available 24 hours aday/7 days a week

New Insurer and Administrator continued from page 1

What’s New• MHSA Insurer:

UnitedHealthcare Insurance Company of New York (UHICNY) • MHSA Administrator:

OptumHealth Behavioral Solutions (OptumHealth)• MHSA Network:

visit www.cs.state.ny.us to find network providersNote: MHSA practitioners and facilities appearing in the 2008 Empire PlanParticipating Provider Directory are no longer correct. Visit the web site orcall OptumHealth to find network providers.

• OptumHealth web site: accessible through the Department of Civil Service web site atwww.cs.state.ny.us

• Claims/General Correspondence Address:OptumHealth Behavioral SolutionsP.O. Box 5190Kingston, NY 12402-5190

• Appeal Address:OptumHealth Behavioral Solutions Attn: BH Appeals Dept.900 Watervliet Shaker RoadSuite 103Albany, NY 12205-1002

• TTY Phone Number: 1-800-855-2881

What’s the Same• MHSA Program• Empire Plan ID card• 1-800-7-NYSHIP phone number; however there will be prompts for 2008

and 2009 benefit questions. Select the 2009 prompt to contact OptumHealth,select the 2008 prompt to contact ValueOptions.

Non-Network Inpatient Care, Partial Hospitalization, IntensiveOutpatient Program, Day Treatment, 23-hour Extended Bed and 72-HourCrisis Bed: 90% of Billed Charges (EMPIRE PLAN AT A GLANCE CORRECTION)The Empire Plan pays up to 90 percent of billed charges for covered acuteinpatient mental health care in an approved hospital or an approved facility. Youpay the remaining 10 percent until you reach an inpatient coinsurance maximumof $1,500 for you, the enrollee, $1,500 for your enrolled spouse/domestic partnerand $1,500 for all enrolled dependent children combined. The Empire Plan thenpays 100 percent of billed charges for covered services. This benefit is not subjectto a deductible.Each coinsurance maximum is applied as follows: You pay the first $500 ofcoinsurance, after which you will be reimbursed for the next $500 of coinsurance,upon written request of the enrollee, then you pay the final $500 of coinsurance.This article also corrects the paragraph explaining Non-Network Coverage for Approved Facilities Under Mental Health Benefits on page 11 of yourEmpire Plan At A Glance.


EPR-PBA-T-09-01 3

About Mental Health and Substance Abuse TransitionQuestions and Answers

What is the transition of care benefit?

The transition of care benefit allows you to continue to receive network benefits even if yourprovider has not joined the OptumHealth network asof January 1, 2009. All levels of care (see page 1) arecovered under the transition of care benefit.

How do I access my transition of care benefit?

You do not need to call or complete any forms to access the transition of care benefit. If youreceived network benefits between July 1, 2008 and December 31, 2008, you will automatically be given the transition of care benefit through March 31, 2009, for services received from the same provider, even if that provider is not in theOptumHealth network. Please note that thesebenefits apply to covered services received betweenJanuary 1, 2009 through March 31, 2009.

If I already have certification from ValueOptions and will be using the transition of care benefit, will my certification from ValueOptions transferover, or do I need to call OptumHealth? You do not have to call OptumHealth, but you maycall if you have questions 24 hours a day, 7 days aweek. Call the NYSHIP toll-free number below, pressOption 3 and select the 2009 MHSA option.

How do I find out if my provider is in theOptumHealth network?Visit www.cs.state.ny.us or call the NYSHIP toll-freenumber below, press option 3 and select the 2009MHSA option for OptumHealth. Provider networkinformation will be updated regularly.

I just checked the web site and my provider is not currently in the OptumHealth network. What are my options?The transition of care benefit allows you to receivenetwork benefits, even if the provider you were seeingin 2008 is not part of the OptumHealth network.When the transition period ends on March 31, 2009,you must use an OptumHealth network provider toreceive the highest level of benefits. You may callOptumHealth at any time to access network benefits.If you continue treatment with your provider afterMarch 31, 2009 and your provider is not part of theOptumHealth network, your treatment will becovered under the non-network benefit, and you willhave higher out-of-pocket costs.

How can my provider become part of theOptumHealth network?If your provider is not currently in the OptumHealthnetwork, you may nominate your provider by callingthe NYSHIP toll-free number below, pressing Option3 and selecting the 2009 MHSA option. Or, yourprovider may call OptumHealth directly at the samenumber.

What if I need treatment after the beginning of the year and I am not eligible for the transition ofcare benefit? To find a network provider for treatment on or afterJanuary 1, 2009, call the NYSHIP toll-free numberbelow, press Option 3 and select the 2009 MHSAoption for OptumHealth.

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The NYSHIP toll-free number is: 1-877-7-NYSHIP (1-877-769-7447).


EPR-PBA-T-09-014

The main features of The Empire Plan2009 Flexible Formulary are:• Copayment levels for generic drugs:

Generic drugs are placed at thelowest copayment level (for example,$5 for a 30-day supply at aparticipating retail pharmacy).

• Coverage for brand-name drugs:Certain brand-name drugs will beexcluded from coverage. If a brand-name drug is excluded, therapeuticbrand-name and/or genericequivalents will be covered.

• Copayment levels for brand-namedrugs: Covered brand-name drugs are classified as preferred or non-preferred and are available at eitherthe second or third copayment levels(for example, preferred brand-namedrugs have a $15 copayment and non-preferred brand-name drugs have a

$40 copayment for a 30-day supply ata participating retail pharmacy).

The following drugs will be excluded fromcoverage under the 2009 Empire PlanFlexible Formulary drug list: Adoxa,Caduet, Coreg CR, Doryx, Genotropin1,Humatrope2, Kapidex, Nexium,Norditropin3, Omnitrope, PrevacidCapsules, Testim, Treximet and Veramyst. As a reminder, the Plan reviews the druglist once a year so in addition to theseexclusions, enrollees may notice otherbrand-name drugs that have a differentcopayment level as of January 1, 2009. If you have been taking one or more ofthese drugs, you should have alreadyreceived a letter informing you of thischange. You may want to discuss analternative medication with your doctorthat will result in your paying a lowercopayment. See your 2009 Empire Plan

At A Glance for a printed copy of theFlexible Formulary drug list or visit theDepartment of Civil Service web site atwww.cs.state.ny.us, select BenefitPrograms, then NYSHIP Online andchoose your group, if prompted.Alphabetic and therapeutic classversions of the 2009 Flexible Formularyare available under the Using YourBenefits button.

1Excluded, except for treatment of growthfailure due to Prader-Willi syndrome orSmall for Gestational Age. Priorauthorization is required.

2Excluded, except for treatment of growthfailure due to SHOX deficiency. Priorauthorization is required.

3Excluded, except for treatment of shortstature associated with Noonan syndrome or small for Gestational age. Priorauthorization is required.

Flexible Formulary continued from page 1

The Empire Plan Half Tablet Program Lowers Your Prescription CostsThis voluntary program allows you toreduce the out-of-pocket cost of selectgeneric and brand-name drugs you takeon a regular basis by:• allowing your physician to write a

prescription for twice the dosage ofyour medication and half the numberof tablets (see Example).

• having you split the pills in half usingthe free pill splitter that The EmpirePlan will provide and

• instructing the participating retail pharmacy or the mail servicepharmacy to automatically reduce your copayment to half the normal charge:

ExampleOld Prescription: .............Lipitor 10 mgQuantity:.................................30 tabletsDosage: .....Take 1 tablet every morningCopayment .......................................$15

New Prescription:............Lipitor 20 mgQuantity:.................................15 tabletsDosage: ....Take ½ tablet every morningCopayment ....................................$7.50

Splitting Tablets is EasyUsing a tablet splitter makes splittingyour medication easy. Never attempt to split tablets with anything other than a device designed specifically forthat purpose. Not all medications areappropriate for tablet splitting. Consultyour doctor before splitting anyprescribed medication.

Order Free Tablet SplitterThe Empire Plan will offer a free tabletsplitter to each enrollee who is currentlyprescribed a drug that is covered as partof the Half Tablet Program. If you are ona medication eligible for the half-tabletprogram, you will receive a welcomeletter with details on how to order yourfree tablet splitter.

Instant Rebate for Omeprazole(generic Prilosec)For a limited time only, The EmpirePlan Prescription Drug Program willoffer an instant rebate of your fullcopayment for omeprazole, thegeneric version of Prilosec (theoriginal “purple pill”). Thismedication is a proton pumpinhibitor used in the treatment ofpeptic ulcers, gastroesophageal refluxdisease (GERD) and othergastrointestinal symptoms.The instant rebate will apply to allomeprazole prescriptions filled atparticipating retail pharmacies or at a mail service pharmacy betweenJanuary 1 and April 30, 2009. Toreceive your rebate (zero copayment),simply present your prescription to your retail pharmacy or send it to the mail service pharmacy. AfterApril 30, 2009, you will pay theapplicable generic copayment ($5 or $10) for subsequent refills. If youhave questions about this rebate oryour drug benefit, call The EmpirePlan Prescription Drug Program at 1-877-7-NYSHIP (1-877-769-7447)and choose option 4.


EPR-PBA-T-09-01 5

Why are some medications being excluded?

Certain drugs are being excluded under The EmpirePlan Prescription Drug Program so that we cancontinue to provide the best value in prescriptiondrug coverage to all enrollees under the Plan.Whenever a prescription drug is excluded, therapeuticbrand and/or generic equivalents will be covered.

Why is Nexium excluded from the 2009 Empire Plan Flexible Formulary? Independent studies conducted by Consumer Reports,the Oregon Health Resources Commission, and AARP, to name a few, have found that there is littleclinical difference in efficacy or adverse effects in theclass of prescription drugs that Nexium belongs to - proton pump inhibitors (PPIs). There is, however, asignificant difference in the cost. The 2009 EmpirePlan Flexible Formulary continues to cover genericand other preferred brand-name PPIs that provide the best value to the Plan.

How do I qualify for the four-month instant rebate ofthe copay for the drug omeprazole (for PPI utilizers)?All prescriptions filled for omeprazole betweenJanuary 1, 2009 and April 30, 2009 will automaticallyreturn a zero copayment. You do not have to enroll,or pre-qualify for the zero copayment.

How will I know if my drug is excluded from the2009 Empire Plan Flexible Formulary? Letters were mailed in late November to all enrolleeswho took an excluded medication in the previous four months to notify them of the change and offercovered equivalents. The listing of drug exclusions is included on the last page of the Flexible Formulary drug list. The list was sent to enrollees as part of the2009 Empire Plan At A Glance and can be requestedthrough customer service by calling 1-877-7NYSHIP (1-877-769-7447) and choosing Option 4. It is alsoavailable on the New York State Department of CivilService web site at www.cs.state.ny.us, and was mailed toall Empire Plan Participating Physicians and enrollees.

How will my local pharmacist know my drug isexcluded? Your local participating pharmacist will receive amessage when your claim is processed which willadvise that the drug is not covered under The EmpirePlan. If you choose to fill the prescription, you will beresponsible for paying the full cost of the drug; The

Empire Plan will not reimburse you for any portionof the cost.

What will happen if I send a new prescription orrequest a refill from Medco by Mail for an excludeddrug?If you call in a refill of an excluded drug through amail service pharmacy, the customer servicerepresentative or interactive voice response systemwill advise you that the drug is excluded, and yourorder will be cancelled. If you mail in a refill order,you will receive a letter indicating your drug is nolonger covered under the Plan. If you mail in a newprescription for an excluded drug, the mail servicepharmacy will return the prescription along with aletter advising that the drug is excluded from EmpirePlan coverage and can no longer be dispensed.

How will my physician know that my drug isexcluded? The 2009 Flexible Formulary drug list was sent to allparticipating physicians in The Empire Plan Network.Additionally, if your physician utilizes an online methodof prescribing known as E-Prescribing, a message willbe displayed indicating that the drug is not covered.

Where can I find lower cost alternatives to thedrug I am taking?Suggested generic and/or preferred brand-name drugequivalents are listed on the last page of the FlexibleFormulary drug list. We recommend that you talkwith your physician to identify which medication isappropriate to treat your condition.

How do I change to one of the preferredmedications on The Empire Plan FlexibleFormulary? Will I need a new prescription? Yes, you will need a new prescription. If you are almostout of medication, you can request that your retailpharmacist call your physician for a new prescriptionof a generic or preferred brand-name drug. If you use a mail service pharmacy, the mail servicepharmacy will assist you with obtaining a newprescription. Please call customer service at 1-877-7-NYSHIP (1-877-769-7447) and chooseOption 4 for assistance.

Can I appeal a drug exclusion or tier placement?

No. Drug exclusions and level placements are acomponent of your Benefit Plan Design and cannotbe appealed.

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About The Empire Plan Flexible Formulary Questions and Answers


EPR-PBA-T-09-016

The Empire Plan Medical/Surgical Benefits Program$30 Copayment for Non-HospitalOutpatient Surgical LocationsBeginning January 1, 2009, you pay thefirst $30 in charges (copayment) foreach visit to an outpatient surgicallocation that has an agreement in effectwith UnitedHealthcare.The $30 copayment covers your electivesurgery and anesthesiology, radiology and laboratory tests performed on the day of the surgery at the sameoutpatient surgical location.

Herpes Zoster Vaccine for ShinglesEffective January 1, 2009, the HerpesZoster Vaccine used to prevent shingles iscovered as an adult immunization underthe Participating Provider Program forindividuals age 55 or over. Since shinglesusually occurs in the senior population,this coverage is consistent withestablished clinical guidelines. You payonly the office visit copayment when youreceive the Herpes Zoster vaccinationfrom a Participating Provider. There is no non-network benefit.

Prosthetic Wig BenefitEffective January 1, 2009, wigs will becovered under the Basic MedicalProgram when hair loss is due to anacute or chronic condition that leads tohair loss including, but not limited to:• Disease of endocrine glands such as

Addison’s disease and ovarian genesis• Generalized disease affecting hair

follicles such as systemic lupus andmyotonic dystrophy

• Systemic poisons such as Thallium,Methotrexate and prolonged use ofanticoagulants

• Local injury to scalp such as burns,radiation therapy, chemotherapytreatment and neurosurgery

Excluded from coverage is male andfemale pattern baldness.

There is a lifetime maximum benefit of$1,500 per individual regardless of thenumber of wigs purchased. Benefits arenot subject to the Basic Medicaldeductible or coinsurance. Claimssubmitted for the prosthetic wig benefitmust include documentation from the treating physician that states that the individual has a diagnosis for acovered condition.

Participating Diabetes Education CentersDiabetes education can be an importantpart of a treatment plan for diabetes.Diabetes educators provide information on nutrition and lifestyle improvementthat can help diabetics better managetheir disease. The Empire Plan networknow includes Diabetic Education Centersthat are accredited by the AmericanDiabetes Association EducationRecognition Program. If you have adiagnosis of diabetes, your visits to anetwork center for self-managementcounseling are covered and you pay onlyan office visit copayment for each coveredvisit. Covered services at a non-networkdiabetes education center are consideredunder the Basic Medical Program subjectto deductible and coinsurance.To find an Empire Plan participatingdiabetes education center, call The Empire Plan toll free at 1-877-7-NYSHIP(1-877-769-7447) and chooseUnitedHealthcare. Or, go to the NewYork State Department of Civil Serviceweb site (www.cs.state.ny.us), click onBenefit Programs and then NYSHIPOnline. Select your group if prompted,click on Find a Provider and thenMedical and Surgical Providers underUnitedHealthcare.

Diabetic ShoesEffective January 1, 2009, one pair of custom molded or depth shoes per calendar year are a covered expense under The Empire Plan if: • You have a diagnosis of diabetes

and diabetic foot disease;

• Diabetic shoes have been prescribed by your provider; and

• The shoes are fitted and furnished by a qualified perdorthist, orthotist,prosthetist or podiatrist. Shoesordered by mail or from the internetare not eligible for benefits.

When you use an HCAP-approvedprovider for medically necessary diabeticshoes, you receive a paid-in-full benefitup to an annual maximum benefit of$500. To ensure that you receive themaximum benefit, you must make a pre-notification call to the Home Care Advocacy Program (HCAP). Youmust call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447),choose UnitedHealthcare and then the Benefits Management Program.HCAP will assist you in makingarrangements to receive networkbenefits for diabetic shoes.If you do not receive medicallynecessary diabetic shoes from an HCAP-approved provider, benefits will beconsidered under the Basic MedicalProgram subject to the annualdeductible with any remaining coveredcharges paid at 75% of the networkallowance with a maximum annualbenefit of $500.

Centers of Excellence Programs for Transplants and CancerEffective January 1, 2009, when you use a Center of Excellence for Transplants that has been pre-authorized by EmpireBlueCross BlueShield or a Center ofExcellence for Cancer that has been pre-authorized by UnitedHealthcare and theCenter of Excellence is more than 100miles from the enrollee’s residence (200miles for airfare), The Empire Planprovides travel, meals and one lodging per day for the patient and one travelcompanion. The Empire Plan willreimburse for meals and lodging based on the United States General Services

Empire Plan Benefit Changes Effective January 1, 2009

Benefit Changes continued on page 7


EPR-PBA-T-09-01 7

Benefit Changes continued from page 7Administration (GSA) per diem rate andautomobile mileage (personal or rentalcar) based on the Internal RevenueService medical rate. The following arethe only additional travel expenses thatare reimbursable: economy class airfare,train fare, taxi fare, parking, tolls andshuttle or bus fare from your lodging tothe Center of Excellence. To find thecurrent per diem rates for lodging andmeals, visit the United States GeneralServices Administration web site atwww.gsa.gov and look under TravelResources. Travel and lodging benefits areavailable as long as the patient remainsenrolled and receiving benefits under theCenters of Excellence programs forTransplants or Cancer. The $10,000lifetime maximum for travel, meals andlodging for the Centers of Excellence forCancer Program has been eliminated.

Kidney Resource Services ProgramEffective January 1, 2009, The EmpirePlan will offer a Kidney Resource ServicesProgram to its enrollees when TheEmpire Plan is your primary healthinsurance coverage. If you or yourdependents have been diagnosed withChronic Kidney Disease (CKD), you maybe invited to participate in this diseasemanagement program. Participation isvoluntary, free of charge and confidential.

If you agree to participate, you willreceive information to help you betterunderstand your condition. You will beoffered educational materials and otherservices that may help to improve themanagement of your kidney disease. Youmay also be contacted by a RegisteredNurse in conjunction with this program.This program works in partnership with your physician to achieve the bestpossible health outcomes.If you have questions or would like moreinformation, call The Empire Plan tollfree at 1-877-7-NYSHIP (1-877-769-7447)and choose the option for The EmpirePlan NurseLine.

2009 Annual Deductible andCoinsurance Maximum for BasicMedical and Non-Network MentalHealth Practitioner Services Annual Deductible: $363 Coinsurance Maximum: $800For calendar year 2009, The EmpirePlan annual deductible for servicesperformed and supplies prescribed by non-participating or non-networkproviders is $363 for you, $363 for your enrolled spouse/domestic partnerand $363 for all covered dependentchildren combined.

You must meet the deductible beforebenefits are paid for your claims. The annual deductible for the BasicMedical Program and the non-networkportion of the Mental Health Programcannot be combined with each other or with the Managed Physical MedicineProgram annual deductible for non-network services.Effective January 1, 2009, there is aseparate annual coinsurance maximum (out-of-pocket expense) of $800 for you,$800 for your enrolled spouse, domesticpartner and $800 for all covereddependent children combined in 2009.After each coinsurance maximum isreached, you will be reimbursed 100 percent of the reasonable andcustomary amount, or 100 percent of the billed amount, whichever is less,for covered services. You will still beresponsible for any charges above thereasonable and customary amount andfor any penalties under the benefitsmanagement programs.

CAM Program DiscontinuedThe Empire Plan Complementary andAlternative Medicine Program (CAM) wasdiscontinued effective January 1, 2009 inaccordance with negotiated contracts andagreements with unsettled and non-negotiating groups.

Benefits Management ProgramAdditional Imaging Procedures Require ProspectiveProcedure Review (PPR) EffectiveJanuary 1, 2009You must call The Empire Plan BenefitsManagement Program for ProspectiveProcedure Review of the followingoutpatient imaging procedures whenperformed as an elective (scheduled)procedure:• Magnetic Resonance Imaging

(MRI)/Magnetic ResonanceAngiography (MRA)

• Computed Tomography (CT)• Positron Emission Tomography

(PET) Scans

• Nuclear Medicine DiagnosticProcedures

Call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447), and select UnitedHealthcare, thenBenefits Management to reach the Care Coordination Unit.Should you opt to have one of theseprocedures before the review iscompleted or if you do not call theBenefits Management Program beforehaving it and UnitedHealthcaredetermines that the procedure wasperformed on a scheduled (non-emergency) basis and that the procedurewas medically necessary, you areresponsible for paying the lesser of 50

percent of the scheduled amountsrelated to the procedure or $250, plusyour copayment, under the ParticipatingProvider Program.Under the Basic Medical Program, youare liable for the lesser of 50 percent ofthe reasonable and customary chargesrelated to the procedure or $250. Inaddition, you must meet your BasicMedical annual deductible and you mustpay the coinsurance and any providercharges above the reasonable andcustomary amount.If UnitedHealthcare determines that theprocedure was not medically necessary,you will be responsible for the full costof the procedure.


EPR-PBA-T-09-018

NYSHIP Changes Effective January 1, 2009Leaving School Before GraduationBeginning January 1, 2009, an enrolled, full-time student dependent age 21 orolder who completes a semester willcontinue to be covered under NYSHIPuntil the last day of the third monthfollowing the month in which thedependent completes the semesterunless the dependent otherwise losesNYSHIP eligibility. For example, if thedependent child completes the Springsemester in May, the last day of coveragewould be August 31. However, if thedependent reaches age 25 before August 31, coverage ends on the

dependent’s birthday. This coverageextension applies to each semester thedependent child completes, includingthe semester in which the requirementsfor graduation are completed. A semesteris considered to be completed if thestudent attends classes through the lastrequired date of attendance for thesemester, even if a passing grade is notachieved for coursework.If a dependent student age 21 or olderleaves school prior to the successfulcompletion of a semester and proof ofattendance during the semester isprovided, coverage ends on the last dayof the month in which the dependent

attended school or the end of the thirdmonth following the month that the last semester was completed, whicheveris later. If the required proof is notprovided, coverage will end on the firstday of the incomplete semester or threemonths after the previously completedsemester whichever is later.Generally a dependent child over the age of 21 must be a full-time student atan accredited secondary or preparatoryschool, college or other educationalinstitution to be eligible for NYSHIPcoverage. Refer to your GeneralInformation Book for additionaleligibility information for dependentchildren who are disabled, on medicalleave or have military service.

2009 Copayment ChangesEffective January 1:

Participating Provider Program $30 Copayment–Outpatient Surgical Location

Effective July 1: Participating Provider Program $20 Copayment–Office Visit/Office Surgery, Radiology/Diagnostic Laboratory Tests, Free-StandingCardiac Rehabilitation Center Visit, Urgent Care VisitChiropractic Treatment or Physical Therapy Services (Managed Physical Medicine Program) $20 Copayment–Office Visit, Radiology, Diagnostic Laboratory TestsHospital Services (Hospital Program) $20 Copayment–Outpatient Physical TherapyMental Health and Substance Abuse Program $20 Copayment–Visit to Outpatient Substance Abuse Treatment Program $20 Copayment–Visit to Mental Health Practitioner

Prescription Drug ProgramNon-Preferred Brand-Name Drugs

Supply Dispensed Copayment

Up to a 30-day supply from a participatingretail Pharmacy or through the mail service

$40

31- to 90-day supply through mail service

$65

31- to 90-day supply from a participatingretail Pharmacy

$70


EPR-PBA-T-09-01 9

RemindersThe Empire Plan At A Glance andCopayment CardsIn December 2008, your 2009 EmpirePlan At A Glance along with 2009Empire Plan Copayment Cards and the2009 Flexible Formulary List weremailed to your home. All three areimportant pieces to understand your2009 benefits; be sure to read them andkeep them handy.

Reimbursement of the Medicare Part B Income-Related MonthlyAdjustment Amount (IRMAA) for Medicare-Primary EnrolleesMedicare law requires some people topay a higher premium for their MedicarePart B coverage based on their income.If you and/or any of your enrolleddependents are Medicare-primary andreceived a letter from the Social SecurityAdministration (SSA) requiring the payment of an income-relatedmonthly adjustment amount (IRMAA) in addition to the standard 2008Medicare Part B premium ($96.40) for2008, you are eligible to be reimbursedfor this additional premium by NYSHIP. Note: If your 2006 adjusted gross incomewas less than or equal to $82,000($164,000 if you filed taxes as marriedfiling jointly) you are NOT eligible forany additional reimbursement this year.

To claim the additional IRMAAreimbursement, eligible enrollees arerequired to apply for and document theamount paid in excess of the standardpremium. For information on how toapply, a list of the documents required or questions on IRMAA, you may checkthe Department of Civil Service web site at www.cs.state.ny.us. Choose BenefitPrograms on the home page, thenNYSHIP Online and select your group, if prompted. The IRMAA letter, whichwas mailed to Medicare Part Breimbursement-eligible enrollees in October, is available under What’s New on the NYSHIP Online home page.Or call the Employee Benefits Division at 518-457-5754 (if you are located in the518 area code) or 1-800-833-4344 betweenthe hours of 9:00 a.m. and 3:00 p.m.

Pre-Retirement SeminarsThe Governor’s Office of Employeewith the Office of the State Comptrollerpresents Pre-Retirement Seminars. As part of the seminars, a representativefrom the Employee Benefits Division willexplain the New York State HealthInsurance Program (NYSHIP) and yourchoices before you leave the payroll. Call your personnel office to learn ifthere is a seminar available in your areaand to reserve your place. Be sure tobring your personal confirmation letter

from GOER when you attend. The NewYork State Department of Civil Serviceweb site, www.cs.state.ny.us, also has theseminar schedule. Click on BenefitPrograms, select your group and benefitplan if prompted, and then on calendar. Since demand is greater than availableseating at the seminars, you can alsoaccess helpful online pre-retirementresources at www.goer.state.ny.us/train/onlinelearning/pr/intro.html orwww.osc.state.ny.us/retire.

Participating Provider DirectoryThe most up-to-dateparticipating providerinformation is availableon the Department ofCivil Service web siteat ww.cs.state.ny.us.Click on BenefitPrograms and thenon NYSHIP Online. Select your group, if prompted, and then click on Find AProvider. If you need a printed copy ofthe 2008 Empire Plan ParticipatingProvider Directory, see your agencyHealth Benefits Administrator. Butremember that the MHSA listings arenot correct (see page 2).


EPR-PBA-T-09-0110

Participating ProviderChoosing a

The Empire Plan is a unique program that allows you to receive medical/surgicalcare from participating providers or from non-participating providers. By choosinga participating provider, you receive covered services at little or no cost and youdon’t have to file a claim. For certain services, you must call before you receiveservices. Participating providers are providers who have an agreement in effectunder The Empire Plan. They have agreed to bill UnitedHealthcare and to acceptyour copayment, for services subject to a copayment, plus payment directly fromthe Plan as payment-in-full for covered services.

Participating Provider ProgramThe Empire Plan Participating ProviderProgram offers a network of over175,000 physicians and other providerslocated throughout New York State and in many other states as well. You have the freedom to choose anyparticipating provider without a referral.There is, however, no guarantee that aparticipating provider will always beavailable to you.Providers in the network include:doctors, speech therapists, speech-language pathologists, audiologists,podiatrists, laboratories, outpatientsurgical locations, urgent care centers,freestanding cardiac rehabilitationcenters and Centers of Excellence.Certified nurse midwives may also beavailable through participating doctors.Always ask your provider if he or sheparticipates before you receive services.When you use a participating provider,you pay only the applicable copayment.

Ask for a Participating ProviderThe Empire Plan does not require that a participating provider refer you to a participating laboratory, radiologist, specialist or center. It is your responsibility to request aparticipating provider for other services. Explain to your doctor that your out-of-pocket expenses are usually higher if you don’t use aparticipating lab or if a non-participatingradiologist reads your X-ray.Please be aware, too, that providers withmultiple locations may not be EmpirePlan participating providers in alllocations.It is your responsibility to determinewhether a provider is an Empire Planprovider. In Arizona, Connecticut,Florida, New Jersey, North Carolina,South Carolina, Washington D.C., and states adjacent to D.C., ask if thephysician is part of UnitedHealthcare’sOptions Preferred Provider Organization(PPO). In all other states including New York, and for providers other than physicians in the above states, ask if the provider participates in The Empire Plan.

Annual Notice of Mastectomyand Reconstructive SurgeryBenefitsThe Empire Plan covers inpatient hospital care for lymph nodedissection, lumpectomy andmastectomy for treatment of breastcancer for as long as the physicianand patient determine hospitalizationis medically necessary. The Plancovers all stages of reconstructivebreast surgery following mastectomy,including surgery of the other breastto produce a symmetrical appearance.The Plan also covers treatment forcomplications of mastectomy,including lymphedema. Prosthesesand mastectomy bras are covered.Call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and select UnitedHealthcare if you have questions about your coverage for implants, breast forms or otherprostheses related to breast cancertreatment.Empire Plan Benefits ManagementProgram requirements apply. Seeyour Empire Plan Certificate andEmpire Plan Reports.

State of New York Department of Civil Service Employee Benefits Division

Albany, New York 12239518-457-5754 (Albany area)

1-800-833-4344 (U.S., Canada, Puerto Rico, Virgin Islands)

www.cs.state.ny.us

The Empire Plan Report is published by theEmployee Benefits Division of the State ofNew York Department of Civil Service. TheEmployee Benefits Division administers theNew York State Health Insurance Program(NYSHIP). NYSHIP provides your healthinsurance benefits through The Empire Plan.


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The Empire Plan Carriers and ProgramsTo reach any of The Empire Plan carriers, call toll free 1-877-7-NYSHIP (1-877-769-7447).The one number is your first step to Empire Plan information. Check the list below to know which carrier to select.When you call 1-877-7-NYSHIP, listen carefully to your choices and press or say your selection at any time during themessage. Follow the instructions and you’ll automatically be connected to the appropriate carrier. The Empire Plan Hospital Benefits Program Empire BlueCross BlueShield, New York State Service Center, P.O. Box 1407, Church Street Station, New York, NY 10008-1407. Web site: www.empireblue.com. Call for informationregarding hospital and related services.

Benefits Management Program for Pre-Admission Certification You must call Empire BlueCross BlueShieldbefore a maternity or scheduled hospital admission, within 48 hours after an emergency or urgent hospitaladmission and before admission or transfer to a skilled nursing facility (includes rehabilitation facilities).

Centers of Excellence for Transplants Program You must call Empire BlueCross BlueShield before ahospital admission for the following transplant surgeries: bone marrow, peripheral stem cell, cord bloodstem cell, heart, kidney, liver, lung and simultaneous kidney-pancreas. Call for information about Centers of Excellence.

The Empire Plan Medical/Surgical Benefits Program UnitedHealthcare Insurance Company of New York,P.O. Box 1600, Kingston, NY 12402-1600. Web site: www.myuhc.com. Call for information on benefits underParticipating Provider, Basic Medical Provider Discount and Basic Medical Programs, predetermination of benefits,claims and participating providers.

Managed Physical Medicine Program/MPN Call UnitedHealthcare for information on benefits and to findMPN network providers for chiropractic treatment and physical therapy. If you do not use MPN networkproviders, you will receive a significantly lower level of benefits.

Benefits Management Program for Prospective Procedure Review of MRI, MRA, CT, PET scans andNuclear Medicine tests You must call UnitedHealthcare before having an elective (scheduled) procedure ornuclear medicine test.

Home Care Advocacy Program (HCAP) You must call UnitedHealthcare to arrange for paid-in-full homecare services, enteral formulas, diabetic shoes and/or durable medical equipment/supplies. If you do notfollow HCAP requirements, you will receive a significantly lower level of benefits. You must also callUnitedHealthcare for HCAP approval of an external mastectomy prosthesis costing $1,000 or more.

Infertility Benefits You must call UnitedHealthcare for prior authorization for the following QualifiedProcedures, regardless of provider: Assisted Reproductive Technology (ART) procedures including in vitrofertilization and embryo placement, Gamete Intra-Fallopian Transfer (GIFT), Zygote Intra-Fallopian Transfer(ZIFT), Intracytoplasmic Sperm Injection (ICSI) for the treatment of male infertility, assisted hatching andmicrosurgical sperm aspiration and extraction procedures; sperm, egg and/or inseminated egg procurementand processing and banking of sperm and inseminated eggs. Call UnitedHealthcare for information aboutinfertility benefits and Centers of Excellence.

Centers of Excellence for Cancer Program You must call UnitedHealthcare to participate in The EmpirePlan Centers of Excellence for Cancer Program.

The Empire Plan Mental Health and Substance Abuse Program OptumHealth (administrator forUnitedHealthcare), Mailing Addresses: Claims/General Correspondence - OptumHealth Behavioral Solutions,

P.O. Box 5190, Kingston, NY 12402-5190; Appeals - OptumHealth Behavioral Solutions, Attn: BH Appeals Dept., 900Watervliet Shaker Road, Suite 103, Albany, NY 12205-1002. You must call OptumHealth before beginning any non-emergency treatment for mental health or substance abuse, including alcoholism. You will receive the highest levelof benefits by calling and following OptumHealth’s recommendations. In a life-threatening situation, go to theemergency room. Call within 48 hours or as soon as reasonably possible after inpatient admission.

The Empire Plan Prescription Drug Program UnitedHealthcare appeals, grievances, prior authorizationdocumentation, general correspondence: Empire Plan Prescription Drug Program, P.O. Box 5900, Kingston, NY 12402-5900.Claim forms from retail pharmacies: Empire Plan Prescription Drug Program, P.O. Box 14711, Lexington, KY 40512. MailService Pharmacy: Medco, P.O. Box 6500, Cincinnati, OH 45201-6500. For the most current list of prior authorization drugs,call The Empire Plan or go to www.cs.state.ny.us.

The Empire Plan NurseLineSM Call for health information and support, 24 hours a day, seven days a week. To listen to the Health Information Library, enter PIN number 335 and a four-digit topic code from The Empire PlanNurseLine brochure.

Teletypewriter (TTY) numbers for callers when using a TTY device because of a hearing or speech disability:Empire BlueCross BlueShield..........................................................................TTY only: 1-800-241-6894UnitedHealthcare .............................................................................................TTY only: 1-888-697-9054OptumHealth...................................................................................................TTY only: 1-800-855-2881The Empire Plan Prescription Drug Program...................................................TTY only: 1-800-759-1089


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It is the policy of the State of New York Department of Civil Service to provide reasonable accommodation to ensure effective communication ofinformation in benefits publications to individuals with disabilities. These publications are also available on the Department of Civil Service website (www.cs.state.ny.us). Click on Benefit Programs, then NYSHIP Online for timely information that meets universal accessibility standardsadopted by New York State for NYS agency web sites. If you need an auxiliary aid or service to make benefits information available to you, pleasecontact your agency Health Benefits Administrator. New York State and Participating Employer Retirees and COBRA Enrollees: Contact theEmployee Benefits Division at 518-457-5754 (Albany area) or 1-800-833-4344 (U.S., Canada, Puerto Rico, Virgin Islands).

EPR-PBA-T-09-01

CHANGE SERVICE REQUESTED

Please do not send mail or correspondence to the return address. See page 10for address information.

State of New York Department of Civil ServiceEmployee Benefits DivisionP.O. Box 1068Schenectady, New York 12301-1068www.cs.state.ny.us

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Information for the Enrollee, Enrolled Spouse/ Domestic Partner and Other Enrolled Dependents

PBA-T Empire Plan Report – January 2009

This Report was printed using recycled paper and environmentally sensitive inks. NY0793

!

NYSHIP Dependent Eligibility Verification ProjectIn 2009, the New York State HealthInsurance Program (NYSHIP) willconduct an audit of all dependents thathave health care coverage throughNYSHIP. If you have family coverageyou will receive a packet that willinclude a list of your dependents whoare currently enrolled for health carecoverage, along with an eligibilityworksheet and a list of requireddocuments you must provide. You must supply the dependentdocumentation even if you havepreviously done so. Do not submitdocuments now – wait for the packet tobe delivered. Go to www.cs.state.ny.us/nyshipeligibilityproject/index.cfm for

information on the DependentEligibility Verification Project.Bookmark the page and visit itperiodically for the most currentinformation.You must provide the requireddocumentation to ensure that yourenrolled dependents continue to becovered under NYSHIP. Ineligible orunverified dependents will be droppedfrom coverage. The Department of Civil Service iscontracting with BUDCO, a dependentverification specialty company, toconduct the Dependent EligibilityVerification Project.

Waiver of Out-of-Pocket Costs by Non-Participating ProvidersSome non-participating providerswrongly waive out-of-pocket payments(deductible and coinsurance) for Empire Plan enrollees. Waiver of out-of-pocket payments may lead tosubmission of inflated claims, whichunder certain circumstances may beconsidered insurance fraud. You areresponsible for payment of all out-of-pocket amounts. The level of benefits to which you are entitled is based onmeeting all deductible and coinsurancepayments stated in your insurancecertificate. You should discuss this issue and your potential out-of-pocketliability with your non-participatingprovider before you receive services. If you are aware of provider fraud or abuse, call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) and notify the applicable carrier.


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