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

A U G U S T 2 0 0 5

I n T h i s R e p o r t1 Benefit and

Copayment Changes2 Network and

Non-network Hospitals3-4 Benefit Changes

Empire Plan At A Glance

5 Basic Medical ProviderDiscount Program; Centers of Excellence for Cancer Program

6 Empire Plan Prescription Drug Program; NYSHIP Change;Guaranteed Access

7 Questions and Answers

Read this Report for important information about benefit changes.

Hospital Benefits ProgramOutpatient Services in Network Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $35Emergency Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50Physical Therapy in Network Hospital Outpatient Department . . . . . . . . . . . . . . . $15

Participating Provider ProgramOffice Visit/Office Surgery/Radiology/Diagnostic Laboratory Tests . . . . . . . . . . . . . $15Managed Physical Network Program Services by MPN Providers . . . . . . . . . . . . . . $15

Mental Health and Substance Abuse ProgramStructured Outpatient Rehabilitation Program by ValueOptions Network Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15Hospital Emergency Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50

Prescription Drug ProgramSee page 6 for prescription drug copayments.

CopaymentBenefits

The Empire Plan Copayment Changes Effective September 1, 2005

The Empire Plan Benefit Change Highlights

Network and Non-network HospitalsEffective September 1, 2005The Empire Plan Hospital Benefits Program has two levels of benefits – network andnon-network. Network benefits apply when you use hospitals, hospices and skillednursing facilities that participate in the Blue Cross and Blue Shield Association’snetwork. See page 2 for details.Prescription Drug Program – Three Levels, New CopaymentsEffective September 1, 2005Your prescription drug benefit is based on whether a drug is generic, preferred brand-name or non-preferred brand-name. Copayments are based on the drug, thedays’ supply and whether the prescription is filled at a retail pharmacy or the mailservice pharmacy. See page 6 for prescription drug copayments.Basic Medical Provider Discount ProgramAvailable September 1, 2005Under The Empire Plan Basic Medical Provider Discount Program, you receive discountsfor care from certain physicians and other providers who are part of MultiPlan, anationwide organization contracted with United HealthCare. See page 5 for details.Centers of Excellence for Cancer ProgramAvailable July 1, 2005The Empire Plan now offers a Centers of Excellence for Cancer Program. The Programincludes paid-in-full coverage for cancer-related expenses received through a nationwidenetwork known as Cancer Resource Services. See page 5 for details.

SPECIALSECTION

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P L A NREPORT

EPR-PBA-S & T-05-12

and Non-network Hospitals Effective September 1, 2005

Network

Network BenefitsNetwork benefits apply when you usehospitals, hospices and skilled nursingfacilities that participate in the BlueCross and Blue Shield Association’snetwork. This is currently the largesthospital network available in the UnitedStates. Over 90 percent of hospitalsnationwide and every acute care generalhospital in New York State are nownetwork hospitals.Remember to call The Empire Plan tollfree at 1-877-7-NYSHIP (1-877-769-7447)and choose Empire Blue Cross BlueShield before a maternity or scheduledhospital admission, within 48 hoursafter an emergency or urgent hospitaladmission or for admission or transferto a skilled nursing facility. When youcall, customer service representativeswill direct you to a network facility. You continue to receive paid-in-fullbenefits for inpatient hospital, hospiceor skilled nursing facility care at anetwork facility. And, when you use anetwork hospital, services provided byan anesthesiologist, radiologist orpathologist that are related to yourhospital service but billed separately are paid in full under The Empire PlanMedical/Surgical Benefits Program.Please see page 3. Outpatient hospitalservices from a network hospital aresubject to applicable copayment(s).A list of Empire Plan network hospitals,hospices and skilled nursing facilities is available on the New York StateDepartment of Civil Service web site at www.cs.state.ny.us. Click on EmployeeBenefits, then on Empire Plan Providers,Pharmacies and Services. You can alsocall The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) andchoose Empire Blue Cross Blue Shield.

Non-network Benefits If you, your enrolled spouse/domesticpartner or your dependent child choosesto use a non-network hospital, hospice orskilled nursing facility for non-emergencyinpatient care, The Empire Planreimburses you directly for 90 percent of the charges. You pay the remaining 10 percent of the charges until you have reached a coinsurance maximum of $1,500. You, your enrolled spouse/domestic partner and all your dependentchildren combined each have an annualcoinsurance maximum (see below). Youare responsible for full payment to thefacility. For outpatient care, you pay 10 percent or $75, whichever is greater,up to the annual coinsurance maximum. The annual coinsurance maximum (out-of-pocket costs) for services at anon-network facility for either inpatientor outpatient care is $1,500 for theenrollee, $1,500 for an enrolled spouse/domestic partner, and $1,500 for alldependent children combined. Once your out-of-pocket expenses go over$1,500 for non-network inpatient andoutpatient care combined, you willreceive the network level of benefits.

Reimbursement of CoinsuranceMaximum through United HealthCareAfter you have paid $500 out-of-pocketfor yourself, $500 for your enrolledspouse/domestic partner or $500 for allenrolled dependent children, you mayfile a claim with United HealthCare forreimbursement of the next $1,000 incoinsurance. Send a copy of your EmpireBlue Cross Blue Shield Explanation ofBenefits showing you have paid $500out-of-pocket costs along with thecompleted claim form to UnitedHealthCare, P.O. Box 1600, Kingston,New York 12402-1600.

Network Benefits at a Non-network FacilityIf you receive medically necessarycovered services at a non-networkfacility when a network facility isavailable, The Empire Plan provides non-network coverage. However, thePlan will approve network coverage levelunder the following circumstances: • When no network facility can

provide the medically necessaryservices needed.

• When no network facility is availablewithin 30 miles of your residence.

• When an inpatient admission oroutpatient services are certified byEmpire Blue Cross Blue Shield asemergency or urgent care.

Emergency or urgent care delivered at a non-network facility is not subject to the annual coinsurance. Payment for medically necessary coveredemergency or urgent services received in a non-network hospital is madedirectly to you. You pay the emergencyroom copayment.

The following applies to enrollees who have primary coverage through The Empire Plan.

Beginning September 1, 2005, The Empire Plan Hospital Benefits Program has two levels of benefits – network and non-network.

State of New York Department of Civil Service Employee Benefits Division

The State CampusAlbany, New York 12239

518-457-5754 (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.

EPR-PBA-S & T-05-1 3

Benefit Changes Effective September 1, 2005

The Empire Plan

The Empire PlanHospital Benefits Program$50 Copayment for Emergency CareBeginning September 1, 2005, yourcopayment for emergency care in ahospital emergency room is $50. The $50 copayment covers use of thefacility for emergency care and servicesof the attending emergency roomphysician and providers who administeror interpret radiological exams,laboratory tests, electrocardiogram and pathology services.You will not have to pay the $50copayment if you are treated in theemergency room and then admitted at that time as an inpatient.$35 Copayment Per Outpatient VisitBeginning September 1, 2005, your copayment for outpatient services in a network hospital or hospitalextension clinic is $35 for each visitwhere you receive one or more of the following services: surgery,diagnostic radiology, diagnosticlaboratory tests, administration ofDesferal for Cooley’s Anemia.You will not have to pay this $35 facility copayment if you are treated in the outpatient department of thehospital and then admitted at that time as an inpatient. There continues to be no copayment for the following outpatient services in a network hospital: chemotherapy,radiation therapy, dialysis, pre-admissiontesting/pre-surgical testing beforeadmission as an inpatient.$15 Copayment for Physical TherapyBeginning September 1, 2005, yourcopayment is $15 for each visit to theoutpatient department of a networkhospital or hospital extension clinic forphysical therapy when covered underthe Hospital Benefits Program. Pleasesee your Empire Plan Certificate formore information.

Hospital Extension ClinicsEffective September 1, 2005, TheEmpire Plan covers charges, includingfacility charges, for certain hospitalservices provided in a remote location ofa network hospital. This coverageapplies to network hospital owned andoperated on-site facilities and facilitiesnot physically located in the hospitalbuilding, including ambulatory surgicalcenters. The hospital must bill for theservice as part of the hospital’s charges.Your copayment for emergency care ina hospital extension clinic is $50. Yourcopayment for outpatient services in anetwork hospital extension clinic is $35.You will not have to pay the emergencycare or outpatient services copayment ifyou are treated in the extension clinicand it becomes necessary for thehospital to admit you, at that time, asan inpatient. Please see this page andyour Empire Plan Certificate for detailsabout hospital coverage of emergencycare and outpatient services.Non-network hospital benefits apply to services provided at extension clinicsin non-network hospitals. However,network benefits apply to emergencycare. Page 2 of this Report has moreinformation about network and non-network hospitals.

The Empire Plan Benefits Management Program Hospital CoverageEffective September 1, 2005, you will be responsible for the full cost of anyinpatient hospital day determined to be not medically necessary. YourEmpire Plan Certificate has informationabout your right to appeal if you arecharged for inpatient days that can bedocumented as medically necessary.

The Empire PlanMedical/Surgical Benefits Program$15 CopaymentBeginning September 1, 2005, you pay a$15 copayment for services by EmpirePlan participating providers that aresubject to copayments. Such servicesinclude office visits, office surgery,radiology services, diagnostic laboratoryservices, cardiac rehabilitation centervisits, urgent care center visits andcontraceptive drugs and devicesdispensed in a doctor’s office. Yourcopayment for services by ManagedPhysical Network (MPN) providers is also$15 as of September 1, 2005.Radiology, Anesthesiology, PathologyBeginning September 1, 2005, if youreceive radiology, anesthesia or pathologyservices in connection with inpatient oroutpatient hospital services at an EmpirePlan network hospital, covered chargesbilled separately by the radiologist,anesthesiologist or pathologist will bepaid in full by United HealthCare.Services provided by other specialtyphysicians in an Empire Plan networkhospital continue to be consideredunder the Participating ProviderProgram or the Basic Medical Program.Pediatric Immunizations: Meningitis Vaccine AddedEffective May 25, 2005Retroactive to May 25, 2005, meningitisvaccine is covered when provided inaccordance with pediatric immunizationguidelines. Coverage is available underthe Participating Provider Program withno copayment and under the BasicMedical Program subject to deductibleand coinsurance.Your children, up to age 19, are coveredfor routine well-child immunizations andthe cost of oral and injectable substances.

Benefit Changes continued on page 4

EPR-PBA-S & T-05-14

Benefit Changes continued from page 3

The meningitis immunization is coveredfor dependent students age 19 and overunder the Participating ProviderProgram subject to a $15 copayment.Prostheses and Orthotic DevicesEffective September 1, 2005, TheEmpire Plan includes a nationwidenetwork of certified suppliers ofprostheses and orthotic devices underthe Participating Provider Program.When you use an Empire Planparticipating provider, you have a paid-in-full benefit, with nocopayment, for prostheses and orthoticdevices. The Empire Plan benefitprovides for a prosthesis or an orthoticdevice meeting the individual’sfunctional needs. Replacements, whenfunctionally necessary, are also covered.Participating providers will offeradjustments to custom-fitted devicesand appropriate follow-up care. If your need is urgent, and/or you are unable to travel to the provider’soffice, some participating providers will guarantee an appointment withinthree days and will travel up to onehour to your home. Ask the providerdirectly or call United HealthCare at 1-877-7-NYSHIP (1-877-769-7447) toll free.A list of Empire Plan providers ofprostheses and orthotic devices isavailable on the New York StateDepartment of Civil Service web site at www.cs.state.ny.us. Click onEmployee Benefits and choose EmpirePlan Providers, Pharmacies andServices. Or, call United HealthCare at 1-877-7-NYSHIP (1-877-769-7447)toll free.Prostheses and orthotic devices fromnon-network providers are coveredunder the Basic Medical Program.External Mastectomy ProsthesesEffective September 1, 2005, one single or double external mastectomyprosthesis per calendar year is covered in full under the Basic Medical Program. This benefit has nodeductible, coinsurance or copayment.

Any single external mastectomyprosthesis costing $1,000 or morerequires approval through the HomeCare Advocacy Program (HCAP). Call HCAP toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose UnitedHealthCare before you purchase theprosthesis. For a prosthesis requiringapproval, if a less expensive prosthesiscan meet an individual’s functionalneeds, benefits will be available for themost cost-effective choice.After purchasing a mastectomyprosthesis, submit a completed claimform with the original itemized receiptto United HealthCare, P.O. Box 1600,Kingston, New York 12402-1600. UnitedHealthCare will send reimbursement forthe prosthesis directly to you.The Empire Plan continues to covermastectomy bras under the BasicMedical Program. Please see yourEmpire Plan Certificate for information.Hearing AidsBeginning September 1, 2005, underthe Basic Medical Program, coverage for hearing aids, including evaluation,fitting and purchase, increases up to a total maximum reimbursement of$1,200 per hearing aid, per ear. Theincreased benefit is available once inany four-year period for each ear. Forchildren age 12 years and under, theincreased benefit is available once inany two-year period for each ear when the child’s hearing has changedand the existing hearing aid(s) nolonger fills the need.These benefits are not subject todeductible or coinsurance.

The Empire Plan Hospital Benefits Program andMedical/Surgical Benefits ProgramInfertility Benefits MaximumBeginning September 1, 2005, thelifetime maximum for certain infertilitybenefits, called Qualified Procedures,increases to $50,000 per individual. Thisis an increase from the $25,000 lifetimemaximum. Please see your Empire PlanCertificate and Empire Plan Reports forinformation about Empire Plan infertilitybenefits and Qualified Procedures.

The Empire Plan Mental Health and Substance Abuse Program$15 Copayment for OutpatientSubstance Abuse TreatmentBeginning September 1, 2005, you pay a $15 copayment for each visit to an approved Structured OutpatientRehabilitation Program for substanceabuse. The copayment for an outpatientmental health visit remains $15. To qualify for benefits, all coveredservices must be certified as medically necessary by ValueOptions.$50 Copayment for Emergency Care for Mental Health/Substance Abuse TreatmentEffective September 1, 2005, yourcopayment for emergency care in ahospital emergency room is $50. You will not have to pay this $50copayment if you are treated in theemergency room and then admitted at that time as an inpatient. When youreceive medically necessary coveredservices from a non-network provider in a certified emergency, the Programwill provide network coverage until youcan be transferred to a network facility.Substance Abuse Care Lifetime Maximum Effective January 1, 2005The lifetime maximum benefit forsubstance abuse care, includingalcoholism, under non-networkcoverage is $250,000 for you, theenrollee, and $250,000 for each of your covered dependents. This benefit is retroactive to January 1, 2005. Theprevious lifetime maximum forsubstance abuse care was $100,000.

Report continued on page 5

EPR-PBA-S & T-05-1 5

The following applies to enrollees whohave primary coverage through TheEmpire Plan.

Beginning September 1, 2005, The EmpirePlan includes a new program to reduce yourout-of-pocket costs when you use a non-participating provider. This new program,The Empire Plan Basic Medical ProviderDiscount Program, offers discounts fromcertain physicians and other providers who are not part of The Empire Planparticipating provider network. Theseproviders are part of the MultiPlan group, a nationwide provider organizationcontracted with United HealthCare. Providers in the Basic Medical ProviderDiscount Program accept a discounted feefor covered services. Empire Plan BasicMedical Program provisions apply. Youmust meet the annual Basic Medicaldeductible. Your 20 percent coinsurance is based on thediscounted fee, not the provider’s usual feeor the reasonable and customary charges asunder the Basic Medical Program.

You will receive the Basic MedicalProvider Discount Program benefit if allthe conditions below are met:• The Empire Plan is your primary

coverage;• You receive covered Basic Medical

services from the non-participatingprovider;

• The non-participating provider is in theMultiPlan network;

• The MultiPlan provider discounted fee islower than the Basic Medical reasonableand customary allowance; and

• You have met your annual BasicMedical deductible.

The provider will submit claims for you andUnited HealthCare will pay the providerdirectly. Your Explanation of Benefits,which details claims payments, will showthe discount applied to billed charges.If the reasonable and customary allowanceis lower than the discounted fee, the BasicMedical Provider Discount Program willnot apply and you will be responsible for

reimbursing the provider directly andpaying the provider’s usual fee. Coveredbenefits will be paid to you directly and willnot be sent to the provider in this case.To find a provider in The Empire Plan Basic Medical Provider Discount Program,ask if the provider is an Empire PlanMultiPlan provider or call 1-877-7-NYSHIP(1-877-769-7447) toll free, choose UnitedHealthCare and ask a representative forhelp. You can also visit the New York StateDepartment of Civil Service web site atwww.cs.state.ny.us. Click on EmployeeBenefits, then on Empire Plan Providers,Pharmacies and Services.

The Basic Medical ProviderDiscount Program will beespecially helpful to you whenyou or your dependents are

traveling or away at school in an areawhere participating providers are noteasily available. With the addition of thisProgram, you have another way tomanage your health care costs.

Discount Program Available September 1, 2005

Basic Medical Provider

If you or a covered dependent is diagnosedwith cancer, think about using The EmpirePlan Centers of Excellence for CancerProgram. The Program provides paid-in-full coverage for cancer-related expensesreceived through a nationwide networkknown as Cancer Resource Services (CRS). To participate in this voluntary program,you must call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447).Press or say 1 on the main menu forUnited HealthCare and then press or say 5 to connect to a Cancer ResourceServices nurse consultant. Or, call theCRS toll-free number, 1-866-936-6002.Nurses are available from 8 a.m. to 8 p.m.Eastern time, Monday through Fridayexcept holidays.

CRS nurse consultants are experiencedcancer nurses. They can answer yourquestions, help you understand a cancerdiagnosis and cancer treatment optionsand provide support if you or a familymember is diagnosed with cancer. CRSnurses can also help you choose the bestphysician and cancer center for treatmentof the specific kind of cancer. When you use a Center of Excellence forCancer, you receive paid-in-full benefitswith no copayment. The CRS networkincludes many of the nation’s leadingcancer centers. Among them are MemorialSloan-Kettering Cancer Center in New YorkCity, Roswell Park Cancer Institute inBuffalo, and, in Boston, Dana-Farber CancerInstitute, Brigham & Women’s Hospital andMassachusetts General Hospital.

If you choose to go to a Cancer Center ofExcellence located more than 100 milesfrom your home, the Plan will assist youand one travel companion with expensesfor travel, lodging and meals. You can findmore information about Cancer ResourceServices online at www.urncrs.com, theCRS web site.Since the Centers of Excellence for Cancer Program is voluntary, you are still eligible for Empire Plan benefits foryour medically necessary cancer treatmentif you do not use the Program. However,you must follow the requirements of theBenefits Management Program and payany applicable deductible, coinsurance and copayments.

for Cancer Program Available July 1, 2005

Centers of Excellence

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EPR-PBA-S & T-05-16

Up to a 30-day supplyfrom a participating retailpharmacy or through the Express Scripts Mail Service Pharmacy

generic preferred brand-name

non-preferredbrand-name

$5copayment

$15copayment

$30copayment

31- to 90-day supply from a participating retail pharmacy

$10copayment

$60copayment

$30copayment

31- to 90-day supplythrough the ExpressScripts Mail ServicePharmacy

$55copayment

$20copayment

$5copayment

Prescription Drug ProgramThe Empire Plan

Copayment Changes Effective September 1, 2005Beginning September 1, 2005, The Empire Plan Prescription Drug Programincludes generic, preferred brand-name and non-preferred brand-name drugs.Your copayment amount depends on the drug and quantity prescribed and where you fill your prescription.

A list of the most commonly prescribed generic and preferred brand-namedrugs is on the New York State Department of Civil Service web site atwww.cs.state.ny.us. Click on Employee Benefits and choose your group-specificbenefits. Or, call The Empire Plan Prescription Drug Program toll free at 1-877-7-NYSHIP (1-877-769-7447). Choose Express Scripts.

Generic SubstitutionIf your prescription is written for a brand-name drug that has a generic equivalent,The Empire Plan continues to cover only the cost of the drug’s generic equivalent.If your prescription is written for a brand-name drug with a generic equivalent,you pay the non-preferred brand-name copayment plus the difference in costbetween the brand-name and generic drug, not to exceed the full cost of the drug. Certain drugs are excluded from this requirement. You will be responsible for theapplicable preferred brand-name or non-preferred brand-name copayment.Your Empire Plan Certificate has information about appealing the genericsubstitution requirement.

Supply Dispensed

Prescription Drug Copayment Chart

Domestic Partner EligibilityEffective September 1, 2005, to enroll a domestic partner, you must be able to provide proof that you have livedtogether and been financiallyinterdependent for at least six months.Also effective September 1, 2005, there is a one-year waiting period from thetermination date of previous partnercoverage before you may again enroll a domestic partner. Other eligibilityrequirements apply. Please see yourNYSHIP General Information Bookand Empire Plan Reports for details.

NYSHIPChange

“Guaranteed Access”

The Empire Plan has three programsthat guarantee network benefits areavailable to you nationwide: the HomeCare Advocacy Program (HCAP), theManaged Physical Medicine Programand the Mental Health and SubstanceAbuse Program. When you follow each Program’s requirements, youreceive network benefits, the highestlevel of benefits.Home Care Advocacy ProgramTo receive HCAP network benefits forhome care services, durable medicalequipment and supplies, you must:• Call The Empire Plan toll free at

1-877-7-NYSHIP (1-877-769-7447)and select United HealthCare, then the Home Care AdvocacyProgram,* and

• Receive precertification of your homecare and or equipment/supplies fromUnited HealthCare, and

Guaranteed Access continued on page 8

to Network Benefits

EPR-PBA-S & T-05-1 7

About New BenefitsQuestions and Answers

How will I know if my hospital is in The Empire Plan network?A directory of Empire Plan network hospitals isavailable on the New York State Department of CivilService web site at www.cs.state.ny.us. ChooseEmployee Benefits and then click on Empire PlanProviders, Pharmacies and Services. Or, you can call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose Empire Blue Cross Blue Shield to ask a representative.

Is the hospital network access standard of within30 miles of residence always based on mypermanent address?Not necessarily. For example, if you are temporarilyliving in another location or have a dependent, such as acollege student, who is residing at another location, thePlan will approve network coverage at a non-networkhospital if no network facility meets the access standardbased on the place of residence at that time.

If my Empire Plan medical provider has privilegesonly at a non-network hospital and that is the hospitalI use, will I receive network or non-network hospitalbenefits? What if my Empire Plan provider sends meto a non-network hospital for lab work?If you receive services at a non-network hospital and a network hospital is within 30 miles of yourresidence, you will receive non-network benefits and have out-of-pocket expenses. You will also receivenon-network benefits if your provider sends you to anon-network hospital for lab work when a networkhospital is within 30 miles of your residence.

Will I get reimbursed for non-network hospitalcoinsurance amounts?Yes. When your combined coinsurance payments forservices at a non-network facility are more than $500for you, more than $500 for your spouse/domesticpartner or more than $500 for all enrolled dependentchildren, you may send a completed claim form toUnited HealthCare for reimbursement. You will bereimbursed for the amount over $500, up to the non-network hospital coinsurance maximum of $1,500. Anynetwork level copayments paid at non-network hospitals(emergency care copayment) do not count toward thecoinsurance maximum.For example, you receive services at a non-networkhospital and have an out-of-pocket expense of $400 incoinsurance. You again go to a non-network hospitalin the same calendar year and pay another $400

coinsurance. You have a combined out-of-pocketexpense of $800. You can now submit a claim to UnitedHealthCare for reimbursement of $300.How will I know if my prescription is for a generic or a preferred brand-name drug?You’ll find a list of the most commonly prescribedgeneric and preferred brand-name drugs on theDepartment of Civil Service web site atwww.cs.state.ny.us. Choose Employee Benefits and then your group-specific benefits. Or, you maycall The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447). Choose Express Scripts.

Will my doctor know The Empire Plan generic and preferred brand-name drugs?The Empire Plan will provide doctors with the list ofmost commonly prescribed generic and preferred brand-name drugs. But, it is your responsibility to know in which category your drug is listed. Get the list from the web site or the Plan (see above) beforeyour doctor’s appointment.

Does the Basic Medical Provider Discount Program replace the Basic Medical Program?No. The Basic Medical Provider Discount Program ispart of the Basic Medical Program. You may still chooseto receive care under the Participating ProviderProgram. Or, you may choose non-participatingproviders under the Basic Medical Program.

Why would I use the Basic Medical ProviderDiscount Program?When a participating provider is not available, or youchoose to go to a non-participating provider, the BasicMedical Provider Discount Program (MultiPlan) cansave you money. After you meet your deductible, youare responsible for 20 percent of the discounted fee.The MultiPlan provider cannot balance bill you foramounts exceeding the discounted fee.

For example, you have met your deductible for theyear and receive services costing $200. The MultiPlandiscounted fee is $140. Your cost is $28 (20 percent ofthe discounted fee). Plus, the provider submits theclaim for you and United HealthCare pays the provider.

In contrast, for the same $200 cost of services under theBasic Medical Program for non-participating providers,The Empire Plan pays $128 (80 percent of the reasonableand customary charge of $160). Your cost is $72 (thedifference between $200 and $128). And, you must filethe claim for reimbursement yourself.

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EPR-PBA-S & T-05-18

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 web site(www.cs.state.ny.us). Click on Employee Benefits for timely information that meets universal accessibility standards adopted by New York State for NYS Agency web sites. If you need an auxiliary aid or service to make benefits information available to you, please contact your agency HealthBenefits Administrator. COBRA Enrollees: Contact the Employee Benefits Division at 518-457-5754 (Albany area) or 1-800-833-4344 (U.S., Canada,Puerto Rico, Virgin Islands).

EPR-PBA-S & T-05-1

ADDRESS SERVICE REQUESTED

State of New York Department of Civil ServiceEmployee Benefits DivisionThe State CampusAlbany, New York 12239www.cs.state.ny.us

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

PBA-S and PBA-T Empire Plan Report – August 2005

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• Use an HCAP-approved provider for covered services and/orequipment/supplies.

*Exception: For diabetic supplies (except insulin pumps and Medijectors)or ostomy supplies, contact the HCAPnetwork providers directly and toll free:National Diabetic Pharmacies (NDP), 1-888-306-7337 for diabetic supplies. (For insulin pumps and Medijectors, you must call HCAP for authorization.)Byram Healthcare Centers, 1-800-354-4054 for ostomy supplies. Managed Physical Medicine ProgramTo receive network benefits forchiropractic treatment and physicaltherapy, you must use a ManagedPhysical Network (MPN) networkprovider for medically necessaryservices. You are not required to callMPN before your visit. You may contacta provider directly and ask if the

provider is in the network. Or, you may call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) andchoose United HealthCare. UnitedHealthCare will help you find an MPNnetwork provider. If there are no network providers in yourarea, MPN will arrange for you to receivemedically necessary services withnetwork benefits. You will pay only yourcopayments for each visit. But, you mustcall United HealthCare before you receiveservices and you must use the providerwith whom MPN has arranged your care.Mental Health and Substance Abuse ProgramTo receive network benefits for mental health or substance abuse care,including care for alcoholism, you must call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) andchoose ValueOptions before you seek

treatment, and you must use aValueOptions network provider.If there are no network providers inyour area, ValueOptions will arrange for you to receive medically necessaryservices with network benefits from anon-network provider or facility. But,you must call ValueOptions before youreceive services and you must use theprovider with whom ValueOptions hasarranged your care.For More InformationPlease see your Empire Plan Certificatefor more information about the HomeCare Advocacy Program, the ManagedPhysical Medicine Program and theMental Health and Substance AbuseProgram and for requirements inemergency situations. Remember: If you follow program requirements,you are guaranteed network benefits,the highest level of coverage.

Guaranteed Access to Network Benefits continued from page 6

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