for employees of the state of new york units that …...for employees of the state of new york who...

For Employees of the State of New York who are unrepresented or in Negotiating Units that have agreements/awards with New York State beginning April 1, 2007,Employees of Participating Employers and for COBRA enrollees with their NYSHIP benefits(Check with your agency Health BenefitsAdministrator or union if you are uncertain.)

Health Insurance ChoicesChoose your Health Insurance Plan and Pre-Tax Status for 2009

October 2008

Choicesfor 2009

i Choices 09/Actives Settled

ContentsPre-Tax Status, November 30 Deadline ......................i

Biweekly Premium Contribution ................................1

Information and Reminders.....................................1-2

Choosing Your Health Plan.....................................2-3

Benefits All NYSHIP Plans Provide...........................3

The Empire Plan or a NYSHIP HMO ....................4-7

Similarities and Differences .....................................8-9

Questions and Answers .............................................10

Terms to Know ..........................................................11

Making a Choice .......................................................12

Plans by County ...................................................13-14

The Empire Plan Summary..................................15-19

NYSHIP Health Maintenance Organizations.....20-43

New York State Department of Civil Service Web Site...............................................................44-45

Choose Your Health Insurance PlanThis booklet explains the options available to youunder the New York State Health Insurance Program(NYSHIP). Choose either The Empire Plan or one of the NYSHIP-approved Health MaintenanceOrganizations (HMOs) in your area. Consider yourhealth insurance options carefully. You may not changeyour health insurance option after the deadline exceptin special circumstances. (See your NYSHIP GeneralInformation Book and Empire Plan Reports or HMOReports for details about changing options outside theOption Transfer Period.) If you still have specificquestions after you’ve read the plan descriptions,contact The Empire Plan carriers and HMOs directly.

Rates for 2009 and Deadline for Changing PlansThe Empire Plan and HMO rates for 2009 are mailedto your home and posted on our web site as soon asthey are approved. (Participating Employers, such as theThruway Authority and MTA, will notify their enrollees of 2009 rates.) The rate flyer announces the optionchange deadline and paycheck deduction dates. Youhave 30 days from the date your agency receives rateinformation to make a decision. Rates are posted onthe New York State Department of Civil Service website at www.cs.state.ny.us as soon as they are approved.Click on Benefit Programs, then on NYSHIP Online.Select your group if prompted, and then click onHealth Benefits & Option Transfer. Choose Rates andHealth Plan Choices. Your agency Health BenefitsAdministrator or HBA can help if you have questions.

COBRA enrollees may contact the Employee BenefitsDivision at 518-457-5754 (Albany area) or 1-800-833-4344 (U.S., Canada, Puerto Rico and the Virgin Islands).

See your agency Health Benefits Administrator to change your health insurance option, enrollment or pre-tax status.

NO ACTION IS REQUIRED IF YOU DONOT WISH TO MAKE CHANGES.

Changes are not automatic and deadlines apply. You must report any change that may affect your coverage to your agency Health BenefitsAdministrator. See pages 1 and 2 in this bookletand your NYSHIP General Information Book forcomplete information.

Choose Your Pre-Tax Contribution ProgramStatus by November 30, 2008The following does NOT apply to employees ofParticipating Employers. Ask your agency Health BenefitsAdministrator (HBA) if a Pre-Tax Contribution Program(PTCP) is available to you. Pre-tax does not apply toCOBRA enrollees.

Under the Pre-Tax Contribution Program, your healthinsurance premiums are deducted from your pay beforetaxes are taken out. This lowers your taxable incomeand increases your spendable income. Only theportion of the premium that pays for Individual

During the Option Transfer Period, you may make two important choices for 2009

Choices 09/Actives Settled 1

coverage may be deducted on a pre-tax basis foremployees who provide health benefits for non-federally qualified domestic partners. Your paycheckstub shows whether you are enrolled in PTCP.

• Regular Before Tax Health appears in the Before TaxDeductions column if your health insurance premiumis deducted from your wages before taxes are withheld.

• Regular After Tax Health appears in the After Tax Deductions column if your health insurancepremium is deducted from your wages after taxes are withheld.

• Regular Before Tax Health appears in the BeforeTax Deductions column AND Regular After TaxHealth appears in the After Tax Deductions columnif you have elected pre-tax and have a non-federallyqualified domestic partner. Under federal law, thedomestic partner’s premium cannot be deductedbefore taxes are withheld.

Under PTCP, you can make the following changesonly in November each year:

• Change from Family to Individual coverage whileyour dependents are still eligible for coverage.

• Voluntarily cancel your coverage while you are still eligible for coverage, or

• Opt out of PTCP.

Under Internal Revenue Service (IRS) rules, you maychange your health insurance deduction during the taxyear only after a PTCP-qualifying event. For a list ofPTCP-qualifying events, see your NYSHIP GeneralInformation Book. T o change your pre-tax selection for 2009, see your agency HBA and complete a health insurance transaction form (PS-404) byNovember 30, 2008.

Your Biweekly Premium ContributionThe following does NOT apply to employees ofParticipating Employers. Participating Employers willprovide premium information. It also does not apply to COBRA enrollees.

New York State helps pay for your health insurancecoverage. After the State’s contribution, you areresponsible for paying the balance of your premiumthrough biweekly deductions from your paycheck.

• For Empire Plan enrollees, the State pays 90 percentof the cost of the premium for enrollee coverage and75 percent of the premium for dependent coverage.

• For HMO enrollees, the State pays 90 percent of the premium for enrollee coverage and 75 percentfor dependent coverage. However, the State’s dollar contribution for the non-prescription drug

components of the HMO premium will NOT exceedits dollar contribution for the non-prescription drugcomponents of The Empire Plan premium.

As soon as they are available, 2009 rates will bemailed to your home and posted on our web site atwww.cs.state.ny.us. Click on Benefit Programs, then on NYSHIP Online. Select your group if prompted,and then click on Health Benefits & Option Transfer.Choose Rates and Health Plan Choices.

Information and RemindersLet Your Agency Know About ChangesYou must notify your agency HBA if your home addressor phone number changes. If you are an active employeeof New York State and registered for MyNYSHIP, youmay also make address and option changes online.

Changes in your family status, such as gaining or losinga dependent, may mean you need to change yourhealth insurance coverage from Individual to Family orfrom Family to Individual. You can make most changesany time, not just during the Option Transfer Period.See your NYSHIP General Information Book for details.Inform your agency HBA about any change promptlyto ensure it is effective on the actual date of change infamily status.

Retiring or Vesting in 2009?You may change your health insurance plan when you retire or vest your health insurance. Retirees andvestees who continue their NYSHIP enrollment maychange health insurance options at any time onceduring a 12-month period. For more information onchanging options as a retiree, ask your agency HBA for Choices for 2009 for Retirees.

Medicare and NYSHIPIf you are an active employee, NYSHIP (The EmpirePlan or a NYSHIP HMO) provides primary coverage foryou and your dependents, regardless of age or disability.

Exceptions: Medicare is primary for your domestic partnerage 65 or over, or for an active employee or dependentwith end-stage renal disease (waiting period applies).

NYSHIP requires you and your dependents to beenrolled in Medicare Parts A and B when first eligiblefor Medicare coverage that pays primary to NYSHIP.

If you are planning to retire, and you or your spouseis 65 or older, contact your Social Security officethree months before active employment ends to enrollin Medicare Parts A and B. Medicare becomes primaryto your NYSHIP coverage the first day of the monthfollowing a “runout” period of 28 days after the payrollperiod in which you retire.

2 Choices 09/Actives Settled

If you or a dependent is eligible for Medicare coverageprimary to NYSHIP but fails to enroll in Parts A andB, The Empire Plan or HMO will not provide benefitsfor services Medicare would have paid if you or yourdependent had enrolled.

Read the following important information if you areplanning to retire or vest in 2009, and consider how yourNYSHIP benefits will be affected when Medicare is yourprimary coverage.

• If you are enrolled in original Medicare (Parts Aand B) and have secondary coverage under TheEmpire Plan: The Empire Plan coordinates benefitswith Medicare. Since Medicare does not providecoverage outside the United States, The EmpirePlan pays primary for covered services receivedoutside the United States.

• If you enroll in a NYSHIP Medicare AdvantagePlan: You replace your original fee-for-serviceMedicare coverage with benefits offered by theMedicare Advantage Plan. Benefits under theHMO’s Medicare Advantage Plan may differ fromyour benefits as an active employee. To qualify forbenefits, all medical care (except for emergency orout-of-area urgently needed care) must be provided,arranged or authorized by the HMO.

• If you enroll in a NYSHIP HMO that coordinatescoverage with Medicare: You receive the same benefitsfrom the HMO as an active employee and still qualifyfor original Medicare benefits if you receive treatmentoutside your HMO.

• If you are enrolled in The Empire Plan and join a Medicare Advantage Plan that is not part ofNYSHIP: If you receive services that are notauthorized by your Medicare Advantage Plan, The Empire Plan will not pay for Medicare-coveredservices that would have been covered by theMedicare Advantage Plan.

Medicare Part D is the Medicare prescription drugbenefit for Medicare-eligible persons. NYSHIPprovides prescription drug benefits to you and yourdependents under The Empire Plan or a NYSHIPHMO. Enrolling in a Medicare Part D plan separatefrom your NYSHIP coverage may drastically reduceyour benefits overall. For example:

• If you are Medicare-primary and enrolled in bothThe Empire Plan and a Medicare D plan, you willnot be able to use your Empire Plan coverage toreceive benefits at the pharmacy. You must use yourMedicare drug coverage first. To receive secondarydrug coverage, you must submit a claim to TheEmpire Plan Prescription Drug Program along withdocumentation of the amount covered by Medicare.

• If you are enrolled in a NYSHIP MedicareAdvantage HMO and then enroll in a Medicare Dplan or another Medicare Advantage Plan outside ofNYSHIP, Medicare will terminate your enrollmentin the NYSHIP HMO.

If you are eligible for the extra help from the MedicarePart D Low Income Subsidy, or if you are interested inadditional drug coverage offered by a Medicare Part Dplan, be sure you understand how joining a Medicareprescription drug plan will change your NYSHIPcoverage before enrolling. If you do enroll in MedicarePart D, you will not be reimbursed for the MedicarePart D premium.

If you receive prescription drug coverage through aunion Employee Benefit Fund, contact the fund forinformation about Medicare Part D.

For more information about NYSHIP and Medicare,ask your agency HBA for a copy of Choices for 2009 forRetirees, Planning for Retirement, Medicare & NYSHIP,Medicare for Disability Retirees and other NYSHIPinformation for retirees.

You will find information in your NYSHIP GeneralInformation Book. Read the chapter titled “Medicare:When You Must Enroll and Coordinating with NYSHIP.”

Choosing Your Health PlanChoosing the health insurance plan to cover your needsand the needs of your family requires careful research.As with most important purchases, there is more toconsider than cost. Selecting a health plan is animportant and personal decision. Only you know yourfamily lifestyle, health, budget and benefit preferences.Think carefully about what you need from your healthplan so you are better prepared to make a choice.

The first step in making a good choice is understandingthe similarities and the differences between your NYSHIPoptions. There are two types of health insurance plansavailable to you under NYSHIP: The Empire Plan andNYSHIP Health Maintenance Organizations (HMOs).The Empire Plan is available to all employees. SpecificNYSHIP HMOs are available in the various geographicareas of New York State. Depending on where you live orwork, one or several NYSHIP HMOs will be available toyou. The Empire Plan and NYSHIP HMOs are similar inmany ways, but also have important differences.

BenefitsThe Empire Plan and NYSHIP HMOs• All NYSHIP plans provide a wide range of hospital,

medical/surgical, and mental health and substanceabuse coverage.


• All plans provide prescription drug coverage if you donot receive it through a union Employee Benefit Fund.

Benefits differ among plans. Read this booklet and thecertificate/contracts carefully for details.

Exclusions• All plans contain exclusions for certain services and

prescription drugs such as those that are consideredcosmetic or experimental.

• Workers’ compensation-related expenses andcustodial care generally are excluded.

For details on exclusions, read your NYSHIP General

Information Book and Empire Plan Certificate or HMOcontract and check with the plan directly.

Geographic Area ServedThe Empire PlanBenefits for all covered services – not just urgent andemergency care – are available worldwide.

Health Maintenance Organizations (HMOs)• Coverage is available in the HMO’s specific

service area.

• An HMO may arrange care outside its service area,at its discretion in certain circumstances.

Benefits Provided by The Empire Plan and All NYSHIP HMOsPlease see the individual plan descriptions in this booklet to review the differences in coverage and out-of-pocket expenses. See plan documents for complete information on benefits.

* Biologically based mental illness and coverage for children with serious emotional disturbance is availablebeyond this limit as defined by Timothy’s Law.

• Inpatient medical/surgical hospital care

• Outpatient medical/surgical hospital services

• Physician services

• Emergency services

• Laboratory services

• Radiology services

• Diagnostic services

• Diabetic supplies

• Maternity, prenatal care

• Well-child care

• Chiropractic services

• Physical therapy

• Occupational therapy

• Speech therapy

• Prosthetics and durable medical equipment

• Orthotic devices

• Bone density tests

• Mammography

• Inpatient mental health services (at least 30 days per calendar year*)

• Outpatient mental health services (at least 20 visits per calendar year*)

• Alcohol and substance abuse detoxification

• Inpatient alcohol rehabilitation (at least 30 days per calendar year)

• Inpatient drug rehabilitation (at least 30 days per calendar year)

• Outpatient alcohol and drug rehabilitation (at least 60 visits per calendar year)

• Family planning and certain infertility services (Call The Empire Plan carriers or HMO for details.)

• Out-of-area emergencies

• Hospice benefits (at least 210 days)

• Home health care in lieu of hospitalization

• Prescription drug coverage including injectablemedications, self-injectable medications,contraceptive drugs and devices and fertility drugs (unless you have coverage through a union Employee Benefit Fund)

• Enteral formulas covered through either HCAPfor The Empire Plan or the HMO’s prescription drug program (unless you have coverage througha union Employee Benefit Fund)

• Second opinion for cancer diagnosis


What’s New in 2009?The Empire Plan

• Beginning January 1, 2009, UnitedHealthcare willinsure and OptumHealth Behavioral Solutions willadminister The Empire Plan Mental Health andSubstance Abuse Program.

• The Empire Plan has a flexible formulary (except for CSEA and Courts) that excludes a small numberof brand-name drugs from coverage.

• The Half Tablet Program: A voluntary program to reduce your out-of-pocket cost on select genericand preferred brand-name medications you take ona regular basis by using higher dosage tablets andsplitting them in half.

NYSHIP HMOsEffective January 1, 2009

• Preferred Care is expanding to Steuben County.

• MVP is expanding to Franklin and St. Lawrencecounties and establishing a new region for these twocounties. The new NYSHIP number is 360.

• MVP Central region (NYSHIP Number 330) will now offer a Medicare Advantage Plan forMedicare-primary enrollees.

• County region change for MVP. Ulster County ischanging from Central 330 to Mid Hudson 340.

The Empire PlanThe Empire Plan is a unique plan designed exclusivelyfor New York State’s public employees. The Empire Planhas many managed care features, but enrollees are notrequired to choose a primary care physician and do not

need referrals to see specialists. However, certain services,such as hospital and skilled nursing facility admissions,certain outpatient radiological tests, mental health and substance abuse treatment, home care and someprescription drugs, require pre-approval. Coverage isavailable worldwide. It is not limited to your geographicarea. The New York State Department of Civil Servicecontracts with major insurance companies (carriers) toinsure and administer different parts of the Plan.

The Empire Plan provides:

• Network and non-network inpatient and outpatienthospital coverage for medical, surgical and maternity care;

• Medical and surgical coverage. Coverage under theParticipating Provider Program or the Basic MedicalProgram and Basic Medical Provider DiscountProgram if you choose a non-participating provider;

• Home care services, diabetic supplies, enteralformulas, durable medical equipment and certainmedical supplies through the Home Care AdvocacyProgram (HCAP);

• Physical medicine (chiropractic treatment andphysical therapy) coverage;

• Inpatient and outpatient mental health andsubstance abuse coverage;

• Prescription drug coverage;

• Centers of Excellence Programs for cancer,transplants and infertility;

• 24-hour NurseLineSM for health information and support; and

• Worldwide coverage.

The Empire Plan or a NYSHIP HMO

Consider CostAlthough New York State pays most of the premium cost for your coverage regardless of which plan youchoose, differences in plan benefits among the various health insurance options result in different employeecontributions for coverage. (See “Your Biweekly Premium Contribution” on page 1.) However, whenconsidering cost, think about all your costs throughout the year, not just your biweekly paycheck deduction.Keep in mind out-of-pocket expenses you are likely to incur during the year, such as copayments forprescriptions and other services, coinsurance and any costs of using providers or services not covered underthe plan. Add the annual premium for that plan to these costs to estimate your total annual cost under thatplan. Do this for each plan you are considering and compare the costs. Watch for the NYSHIP Rates &Deadlines for 2009 flyer that will be mailed to your home and posted on our web site, www.cs.state.ny.us, assoon as rates are approved. Along with this booklet, which provides copayment information, NYSHIP Rates& Deadlines for 2009 will provide the information you need to figure your annual cost under each of theavailable plans.


Cost SharingUnder The Empire Plan, benefits are available forcovered services when you use a participating or non-participating provider. However, your share of the cost of covered services depends on whether theprovider you use is participating or non-participatingunder the Plan.

If you use an Empire Plan participating or networkprovider for medical, surgical, mental health orsubstance abuse services, you pay a copayment forcertain services; some are covered at no cost to you.The provider files the claim and is reimbursed by The Empire Plan.

You are guaranteed access to network benefits forcertain services when you contact the program beforereceiving services and follow program requirements:

• Mental Health and Substance Abuse Program services;

• Managed Physical Medicine Program services(physical therapy and chiropractic care); and

• Home Care Advocacy Program (HCAP) services(home care and services, including durable medicalequipment).

If you use a non-participating provider for medicaland surgical services, benefits for covered services are paid under the Basic Medical Program. After yousatisfy an annual deductible:

• The Empire Plan pays 80 percent of the reasonableand customary charge.

• You are responsible for the 20 percent coinsuranceand charges in excess of the reasonable andcustomary charge.

• After you reach the out-of-pocket maximum, you will be reimbursed up to 100 percent of thereasonable and customary charge. See the chart on page 7 for the Basic Medical deductible andcoinsurance maximum amounts that apply to you,based on your employee group.

• You are responsible for paying the provider and will be reimbursed by the Plan for covered charges.

Basic Medical Provider Discount Program

If you are Empire Plan-primary, The Empire Plan also includes a program to reduce your out-of-pocketcosts when you use a non-participating provider. This program, The Empire Plan Basic MedicalProvider Discount Program, offers discounts fromcertain physicians and providers who are not part of The Empire Plan participating provider network.These providers are part of the nationwide MultiPlangroup, a provider organization contracted withUnitedHealthcare. Empire Plan Basic MedicalProgram provisions apply and you must meet theannual deductible.

Providers in the Basic Medical Provider DiscountProgram accept a discounted fee for covered services.Your 20 percent coinsurance is based on the lower ofthe discounted fee or the reasonable and customary


charge. The provider submits your claims andUnitedHealthcare pays The Empire Plan portion ofthe provider fee directly to the provider if the servicesqualify for the Basic Medical Provider DiscountProgram. Your Explanation of Benefits, which detailsclaims payments, shows the discounted amountapplied to billed charges.

To find a provider in The Empire Plan Basic MedicalProvider Discount Program, ask if the provider is anEmpire Plan MultiPlan provider or call The EmpirePlan toll free at 1-877-7-NYSHIP (1-877-769-7447),choose The Empire Plan Medical Benefits Programand ask a representative for help. You can also visit theNew York State Department of Civil Service web siteat www.cs.state.ny.us. Click on Benefit Programs, then on NYSHIP Online. Select the group if prompted, and then click on Find a Provider.

The best savings are with participating providers. If you choose a non-participating or non-networkprovider for services covered under the Mental Healthand Substance Abuse Program, the Managed PhysicalMedicine Program or the Home Care AdvocacyProgram, benefits for non-network coverage are lower and subject to deductibles, coinsurance andbenefit limits.

ProvidersUnder The Empire Plan you can choose from nearly250,000 participating physicians and other providersnationwide, and from participating pharmacies acrossthe United States or a mail service pharmacy.

Medically necessary visits to specialists are coveredwithout referral or prior authorization. Basic Medicalor non-network benefits are available for coveredservices received from non-participating providers,depending on the type of service.

NYSHIP Health Maintenance OrganizationsA Health Maintenance Organization (HMO) is amanaged care system in a specific geographic area thatprovides comprehensive health care coverage througha network of providers.

• Coverage outside the specified geographic area is limited.

• Enrollees usually choose a primary care physician(PCP) from the HMO’s network for routine medicalcare and referrals to specialists and hospitals whenmedically necessary.

• HMO enrollees usually pay a copayment as a per-visit fee or coinsurance (percentage of cost).

• HMOs have no annual deductible.

• Referral forms to see network specialists usually are required.

• Claim forms rarely are required.

• HMO enrollees who use doctors, hospitals orpharmacies outside the HMO’s network must, in most cases, pay the full cost of services (unlessauthorized by the HMO or in an emergency).

All NYSHIP HMOs provide a wide range of healthservices. Each offers a specific package of hospitalbenefits, medical, surgical and preventive care. Theseservices are provided or arranged by the primary carephysician selected by the enrollee from the HMO’sstaff or physician network.

All NYSHIP HMOs cover inpatient and outpatienthospital care at a network hospital and offerprescription drug coverage unless it is providedthrough a union Employee Benefit Fund.

NYSHIP HMOs are organized in one of two ways:

• A Network HMO provides medical services that can include its own health centers as well as outsideparticipating physicians, medical groups and multi-specialty medical centers.

• An Independent Practice Association (IPA) HMOprovides medical services through private practicephysicians who have contracted independently withthe HMO to provide services in their offices.

Members enrolling in Network and IPA model HMOsmay be able to select a doctor they already know ifthat doctor participates with the HMO.

See the individual HMO pages in this booklet foradditional benefit information and to learn if theHMO serves your geographic area.


Empire Plan Basic Medical Program and Non-Network Mental Health Practitioner Services

Effective January 1, 2009

Employee Group Annual Deductible1 Coinsurance Maximum1

(per enrollee; per spouse or (Out-Of-Pocket Expense perdomestic partner; per all contract for Council 82,

dependent children combined) ALESU, NYSCOPBA and PIAor per enrollee; per spouseor domestic partner; per all

dependent children combinedfor all other groups listed below)

Executive Branch CSEA $225 $500/$3003

DC-37 $281 CPI2 $600 CPI1/$3003

PBA - Troopers $363 CPI2 $800

PBA - Supervisors $363 CPI2 $800

PIA $363 CPI2 $1,345 CPI2

Council 82 $363 CPI2 $1,345 CPI2

ALESU $363 CPI2 $1,345 CPI2

NYSCOPBA $363 CPI2 $1,345 CPI2

UUP $363 CPI2 $1,000

PEF $363 CPI2 $1,000

M/C $363 CPI2 $1,000

Legislature $363 CPI2 $1,000

Participating Employers $363 CPI2 $1,000

Unified Court System $225 $500/$3003

Retirees, Vestees, Dependent Survivors $363 CPI2 $1,000and Preferred List

1 Each program’s deductible, coinsurance and maximum coinsurance amount is separate and not combinedwith any other deductible, coinsurance or maximum coinsurance amount.

2 These changes reflect the 4.1% increase in the medical care component of the Consumer Price Index for UrbanWage Earners and Clerical Workers, all Cities (C.P.I.-W.) for the period July 1, 2007 through June 30, 2008.

3 The coinsurance maximum out-of-pocket expense will be reduced to $300 for calendar year 2009 foremployees in (or equated to) salary grade 6 or below on January 1, 2009. This reduction is not available toJudges and Justices.

Note: You have no deductible or coinsurance when you use Empire Plan participating providers.


The Empire Plan and NYSHIP HMOs: Similarities and Differences

Can I use the hospital of my choice? Yes. You have coverage worldwide, but your benefits differ depending onwhether you choose a network or non-network hospital1. Your benefitsare highest at network hospitalsparticipating in the BlueCross andBlueShield Association BlueCard®

PPO Program, or for mental health or substance abuse care in theOptumHealthSM network.Network hospital inpatient: Paid-in-full hospitalization benefits. Network hospital outpatient andemergency care: Subject to networkcopayments.Non-network hospital inpatient andoutpatient: 10 percent coinsurance2

up to an annual maximum of $1,500per enrollee/spouse or domesticpartner/dependent children combined.Note: $500 of $1,500 coinsurancemaximum is reimbursable under theBasic Medical Benefits Program.

Except in an emergency, you generally do not have coverage at non-participating hospitals unlessauthorized by the HMO.

If I am diagnosed with a seriousillness, can I see a physician or go to a hospital that specializes in my illness?

Yes. You can use the specialist of your choice. You have Basic MedicalProgram benefits for non-participatingproviders and Basic Medical ProviderDiscount Program benefits for non-participating providers who arepart of The Empire Plan MultiPlangroup1. (See pages 5 and 6 for moreinformation on the Basic MedicalProvider Discount Program.) Yourhospital benefits will differ dependingon whether you choose a network ornon-network hospital1. (See above for details.)

You should expect to choose a participating physician and a participating hospital. Under certain circumstances, you may be able to receive a referral to a specialist care center outside the network.

Can I be sure I will not need to pay more than my copayment when I receive medical services?

Yes. Your copayment should be youronly expense if you: • Choose a participating provider;• Receive inpatient or covered

outpatient hospital services at anetwork hospital and follow BenefitsManagement Program requirements1.

Yes. As long as you follow HMOrequirements and receive theappropriate referral, your copayment(or coinsurance) should be your only expense.

The Empire Plan NYSHIP HMOs


1 Applies only to Empire Plan-primary enrollees2 Greater of 10 percent coinsurance or $75 for outpatientNote: These responses are generic and highlight only general differences between The Empire Plan and NYSHIP HMOs. Details foreach plan are available on individual plan pages beginning on page 15 of this booklet, in the Empire Plan Certificate (available fromyour agency Health Benefits Administrator) and in the HMO contract (available from each HMO).

The Empire Plan NYSHIP HMOs

Will I be covered for care I receive away from home?

Yes. Under The Empire Plan, yourbenefits are the same wherever youreceive care.

Under an HMO, you are covered awayfrom home only for emergency care.Some HMOs provide coverage for routine care if the HMO hasreciprocity with another HMO. SomeHMOs provide coverage for collegestudents away from home if the care is urgent or if follow-up care has beenpre-authorized. See the “Out of AreaBenefit” description on each HMOpage for more information.

Do I have coverage for substance abuse treatment?

Yes. You have guaranteed access to unlimited medically necessaryoutpatient care and up to threeinpatient stays per lifetime as long as you follow Plan requirements.

Yes. Coverage is available for aspecified number of days/visits each year, as long as you follow the HMO’s requirements.

What kind of care is available for physical therapy and chiropractic care?

You have guaranteed access tounlimited medically necessary carewhen you choose participatingproviders and follow Plan requirements.

Coverage is available for a specifiednumber of days/visits each year, as longas you follow the HMO’s requirements.

What if I need durable medicalequipment, medical supplies or home nursing?

You have guaranteed, paid-in-fullaccess to medically necessary homecare, equipment and supplies throughthe Home Care Advocacy Program(HCAP) when pre-authorized andarranged by the Plan.

Benefits are available and varydepending on the HMO. Benefits may require a greater percentage of cost-sharing.


Q: Can I join The Empire Plan or any NYSHIP-approved HMO?

A: The Empire Plan is available worldwide, whereveryou live or work. To enroll or continue enrollmentin a NYSHIP-approved HMO, you must live orwork in that HMO’s service area. If you movepermanently out of and/or no longer work in yourHMO’s service area, you must change options. See“Plans by County” on pages 13 and 14 and theindividual HMO pages in this booklet to check the counties each HMO will serve in 2009.

Q: How do I find out which providers and hospitalsparticipate? What if my doctor or other providerleaves my plan?

A: Check with your providers directly to see whetherthey participate in The Empire Plan for New YorkState government employees or in a NYSHIP HMO.

For Empire Plan providers:

• Visit www.cs.state.ny.us; click on Benefit Programs,then on NYSHIP Online. Select your group ifprompted, and then click on Find a Provider.

• Ask your agency Health Benefits Administratorfor The Empire Plan Participating Provider Directory.

• Call The Empire Plan toll free at 1-877-7-NYSHIP(1-877-769-7447) and select the appropriateprogram for the type of provider you need.

For HMO providers:

• Visit the web sites (web site addresses areprovided on the individual HMO pages in thisbooklet) for provider information.

• Call the telephone numbers on the HMO pagesin this booklet. Ask which providers participateand which hospitals are affiliated.

If you choose a provider who does not participate inyour plan, check carefully whether benefits wouldbe available to you. Ask if you need authorization to have the provider’s services covered. In mostcircumstances, HMOs do not provide benefits for

services by non-participating providers or hospitals.Under The Empire Plan, you have benefits forparticipating and non-participating providers.

Participating providers change. You cannot changeyour plan outside the Option Transfer Periodbecause your provider no longer participates.

Q: I have a pre-existing condition. Will I havecoverage if I change options?

A: Yes. Under NYSHIP, you can change your option and still have coverage for a pre-existingcondition. There are no pre-existing conditionexclusions in any NYSHIP plan. However,coverage and exclusions differ. Ask the plan youare considering about coverage for your condition.

Q: What if I retire in 2009 and become eligible for Medicare?

A: Regardless of which option you choose, as a retiree,you and your dependent must be enrolled inMedicare Parts A and B when either of you firstbecomes eligible for primary Medicare coverage.Please read about Medicare and NYSHIP andMedicare Part D on pages 2 and 3.

Please note, especially, that your NYSHIP benefitsbecome secondary to Medicare and that your benefitsmay change when you enroll in some HMOs.

Q: I am a COBRA dependent in a Family plan. Can I switch to Individual coverage and select adifferent health plan from the rest of my family?

A: Yes. As a COBRA dependent, you may elect tochange to Individual coverage in a plan differentfrom the enrollee’s Family coverage. During theOption Transfer Period, you may enroll in TheEmpire Plan or choose any NYSHIP-approvedHMO in the area where you live or work.

Questions and Answers


• Coinsurance: The enrollee’s share of the cost of covered services; a fixed percentage of medical expenses.

• Copayment: The enrollee’s share of the cost ofcovered services that is a fixed dollar amount paidwhen medical service is received, regardless of thetotal charge for service.

• Deductible: The dollar amount an enrollee isrequired to pay before health plan benefits begin to reimburse for services.

• Fee-for-service: A method of billing for health careservices. A provider charges a fee each time anenrollee receives a service.

• Formulary: A list of preferred drugs used by a health plan. If a plan has a closed formulary, youhave coverage only for drugs that appear on the list.If a plan has an open formulary, use of the list isvoluntary. An incented formulary encourages use of preferred drugs to non-preferred drugs based on atiered copayment schedule. In a flexible formulary,brand-name prescription drugs may be assigned todifferent copayment levels based on value to thePlan and clinical judgment. In some cases, drugsmay be excluded from coverage under a flexibleformulary if a therapeutic equivalent or over-the-counter drug is available.

• Health Benefits Administrator (HBA): Personnellocated in each State agency, often in the HumanResources or Personnel Office, who work with theEmployee Benefits Division in the Department ofCivil Service to process enrollment transactions and answer health insurance questions. You areresponsible for notifying your agency HBA ofchanges that might affect your enrollment.

• Health Maintenance Organization (HMO): Amanaged care delivery system organized to deliverhealth care services in a geographic area. An HMOprovides a predetermined set of benefits through a network of selected physicians, laboratories and hospitals for a prepaid premium. Except for emergency services, you and your enrolleddependents may have coverage only for servicesreceived from your HMO’s network.

• Managed Care: A health care program designed toensure you receive the highest quality medical carefor the lowest cost, in the most appropriate healthcare setting. Most managed care plans require you toselect a primary care physician employed by (or whocontracts with) the managed health care system.He/she serves as your health care manager bycoordinating virtually all health care services youreceive. Your primary care physician provides yourroutine medical care and refers you to a specialist if necessary.

• Medicare: A federal health insurance program that covers certain people age 65 or older, disabledpersons under 65, and those who have end-stagerenal disease (permanent kidney failure). Medicare is directed by the federal Centers for Medicare &Medicaid Services (CMS) and administered by theSocial Security Administration.

• Medicare Advantage Plan: Medicare option whereinthe HMO agrees with Medicare to accept a fixedmonthly payment for each Medicare enrollee. Inexchange, the HMO provides or pays for all medicalcare needed by the enrollee. If you join a MedicareAdvantage Plan, you replace your original Medicarecoverage (Parts A and B) with benefits offered by the HMO. Most Medicare Advantage Plans includeMedicare Part D drug coverage. The benefits underthese HMOs are set in accordance with Medicare’sguidelines for Medicare Advantage Plans.

• Network: A group of doctors, hospitals and/or otherhealth care providers who participate in a healthplan and agree to follow the plan’s procedures.

• New York State Health Insurance Program(NYSHIP): NYSHIP covers approximately 1.2 million public employees, retirees anddependents and is one of the largest group healthinsurance programs in the country. The Programprovides health care benefits through The EmpirePlan or a NYSHIP-approved HMO.

• Option: A health insurance plan offered throughNYSHIP. Options include The Empire Plan andNYSHIP-approved HMOs within specificgeographic areas.

Terms to Know


Making a ChoiceDecision-Making ChecklistChoosing a health insurance plan is an importantdecision. Think about what health care you and yourfamily might need during the next year. Review theplans and ask for more information. Here are severalquestions to consider:

• What benefits does the plan have for doctor visitsand other medical care? How are durable medicalequipment and other supplies covered? What is myshare of the cost?

• What benefits does the plan have for prescriptiondrugs? Will the medicine I take be covered underthe plan? (Employees of Participating Employers: If you receive your drug coverage from a union EmployeeBenefit Fund, that coverage will not be affected by achange in your health insurance plan.) What is my shareof the cost? What type of formulary does the planhave? Am I required to use the mail service pharmacy?

• What choice of providers do I have under the plan?(Ask if the provider or facilities you use arecovered.) How would I consult a specialist if Ineeded one? Would I need a referral?

• What is my premium for the health plan?

• What will my out-of-pocket expenses for health care be?

• Does the plan cover special needs? Are there anybenefit limitations? (If you or one of your dependentshas a medical or mental health condition requiringspecific treatment or other special needs, check oncoverage carefully. Don’t assume you’ll have coverage.Ask The Empire Plan carriers or HMOs about yourspecific treatment.)

• Are routine office visits and urgent care covered forout-of-area college students, or is only emergencyhealth care covered?

• How much paperwork is involved in the health plan – do I have to fill out forms?

Things to RememberChoosing a health plan is an important decision.

• Gather as much information as possible.

• Consider the unique needs of yourself and your family.

• Compare the coverage and cost of your options.

• Look for a health plan that provides the bestbalance of cost and benefits for you.

What You Need to DoThe Empire Plan and NYSHIP HMOs are summarizedin this booklet. The Empire Plan is available to allemployees. NYSHIP HMOs are available to employeesin areas where they live or work. Pick the plans thatwould serve your needs best and call each for detailsbefore you choose.

If you decide to change your benefit plan:

• See your agency Health Benefits Administratorbefore the Option Transfer deadline announced in the rate flyer.

• Complete the necessary PS-404 form. Or changeyour option online using MyNYSHIP if you are an active employee of a New York State agency.

How to Use the ChoicesBenefit Charts, Pages 15 – 43All NYSHIP plans must include a minimum level ofbenefits (see page 3). Some benefits are the same. For example, The Empire Plan and all NYSHIPHMOs provide a paid-in-full benefit for medicallynecessary inpatient medical/surgical hospital care atnetwork hospitals.

BENEFITS PROVIDED BY ALL PLANS AT THESAME LEVEL OF COVERAGE (see page 3 ) ARENOT LISTED ON EACH PLAN’S CHART.

Use the charts to compare the differences between plans.The chart lists out-of-pocket expenses and benefitlimitations effective on or about January 1, 2009. See plan documents for complete information on benefit limitations.

A ReminderMost benefits described in this booklet are subject to medical necessity and may involve limitations orexclusions. Please refer to plan documents, or call the plans directly for details.


Plans by CountyThe Empire PlanThe Empire Plan is available to all enrollees in the New York State Health Insurance Program (NYSHIP). You may choose The Empire Plan regardless of where you live or work. Coverage is worldwide. See pages 15-19for a summary of The Empire Plan.

Health Maintenance Organizations (HMOs)Most NYSHIP enrollees have a choice among HMOs. You may enroll – or continue to be enrolled – in anyNYSHIP-approved HMO that serves the area where you live or work. You may not be enrolled in an HMOoutside your area. This list will help you determine whichHMOs are available by county. The pages indicated willdescribe benefits available from each HMO.

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*Medicare-primary NYSHIP enrollees will be enrolled in this HMO’s Medicare Advantage Plan. For more information about NYSHIPMedicare Advantage Plans, ask your agency Health Benefits Administrator for a copy of Choices for 2009 for Retirees.

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NYSHIP CODE

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Bronx

Broome

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Cayuga

Chautauqua

Chemung

Chenango

Clinton

Columbia

Cortland

Delaware

Dutchess

Erie

Essex

Franklin

Fulton

Genesee

Greene

Hamilton

Herkimer

Jefferson

Kings

Lewis

Livingston

Madison


*Medicare-primary NYSHIP enrollees will be enrolled in this HMO’s Medicare Advantage Plan. For more information about NYSHIPMedicare Advantage Plans, ask your agency Health Benefits Administrator for a copy of Choices for 2009 for Retirees.

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Page in Choices

NYSHIP CODE

Monroe

Montgomery

Nassau

New York

Niagara

Oneida

Onondaga

Ontario

Orange

Orleans

Oswego

Otsego

Putnam

Queens

Rensselaer

Richmond

Rockland

Saratoga

Schenectady

Schoharie

Schuyler

Seneca

St. Lawrence

Steuben

Suffolk

Sullivan

Tioga

Tompkins

Ulster

Warren

Washington

Wayne

Westchester

Wyoming

Yates

New Jersey


The Empire Plan NYSHIP Code Number 001This section summarizes benefits available under each portion of The Empire Plan as of January 1, 20091. You may also visit www.cs.state.ny.us, or call toll free 1-877-7-NYSHIP (1-877-769-7447), the one number for The Empire Plan carriers. Call 1-877-7-NYSHIP toconnect to:

The Empire Plan Medical Benefits ProgramUnitedHealthcare

Medical and surgical coverage through:

• Participating Provider Program – More than125,000 physicians and other providers participate;certain services are subject to a $12, $15, $18 or $20copayment, depending on your group.

• Basic Medical Program – If you use a non-participating provider. See “Cost Sharing” (page 5)for an explanation of reimbursement under TheEmpire Plan Basic Medical Program.

• Basic Medical Provider Discount Program – If you use a non-participating provider who is part of The Empire Plan MultiPlan group (see page 5).

Home Care Advocacy Program (HCAP) – Paid-in-full benefit for home care, enteral formulas,durable medical equipment and medical supplies(including diabetic and ostomy supplies). Guaranteedaccess to network benefits nationwide. Limited non-network benefits available. (See the Empire PlanCertificate/Reports for details).

Managed Physical Medicine Program – Chiropractictreatment and physical therapy through a ManagedPhysical Network (MPN) provider – $12 or $18copayment, depending on your group (effective July 1,2009, $15 or $20 copayment). Unlimited networkbenefits when medically necessary. Guaranteed accessto network benefits nationwide. Limited non-networkbenefits available.

Under The Empire Plan Benefits ManagementProgram, you must call UnitedHealthcare forcertification before an elective (scheduled) MagneticResonance Imaging (MRI), Magnetic ResonanceAngiography (MRA), Computerized Tomography(CT), Positron Emission Tomography (PET) scan or Nuclear Medicine test unless you are having thetest as an inpatient in a hospital.

When arranged by UnitedHealthcare, voluntary, paid-in-full Specialist Consultant Evaluation is available.

Voluntary outpatient Medical Case Management is available to help coordinate services for serious conditions.

The Empire Plan Hospital Benefits ProgramEmpire BlueCross BlueShield

The following benefit level applies when coveredservices are received at a BlueCross and BlueShieldAssociation BlueCard® PPO network hospital:

• Medical or surgical inpatient stays are covered at no cost to you.

• Hospital outpatient and emergency care are subjectto network copayments.

• When you use a network hospital, anesthesiology,pathology and radiology provider charges for coveredhospital services are paid in full under the MedicalBenefits Program.

• Certain covered outpatient hospital services providedat network hospital extension clinics are subject tohospital outpatient and emergency care copayments.

The following benefit level applies for servicesreceived at non-network hospitals (for Empire Plan-primary enrollees only2):

• Non-network hospital inpatient stays and outpatientservices – 10 percent coinsurance3 up to annualmaximum of $1,500 per enrollee/spouse or domesticpartner/dependent children. Up to $500 of thecoinsurance may be reimbursed under the BasicMedical Program.

The Empire Plan will approve network benefits at anon-network facility if:

• Your hospital care is emergency or urgent.

• You do not have access to a network facility within30 miles of your residence.

• No network facility can provide the medically necessary services.

• Another insurer or Medicare provides your primarycoverage (pays first).


Pre-Admission Certification Requirements

Under The Empire Plan Benefits ManagementProgram, if The Empire Plan is your primary coverage,you must call Empire BlueCross BlueShield forcertification of any inpatient stay:

• Before a maternity or scheduled (non-emergency)hospital admission

• Within 48 hours after an emergency or urgenthospital admission

• Before admission or transfer to a skilled nursing facility

If you do not follow the pre-admission certificationrequirement, you must pay:

• A $200 hospital deductible if it is determined any portion was medically necessary, and

• all charges for any day determined not to bemedically necessary.

The Empire Plan Mental Health and Substance Abuse ProgramUnitedHealthcare/OptumHealth

The Empire Plan Mental Health and Substance Abuse Program offers two levels of benefits. If you call OptumHealth before you receive services andfollow their recommendations, you receive:

Network Benefits

Mental Health Services (unlimited when medically necessary)

• Inpatient (paid in full)

• Crisis intervention (up to three visits paid in full)

• Outpatient including office visits, home-based ortelephone counseling and nurse practitioner services$12 or $18 copayment, depending on your group;$15 or $20 copayment effective July 1, 2009.

Alcohol/Drug Abuse Services

• Inpatient rehabilitation (paid in full)

• Outpatient rehabilitation to an approved StructuredOutpatient Rehabilitation Program (unlimited when medically necessary). Subject to a $12 or $18 copayment, depending on your group; $15 or $20 copayment effective July 1, 2009.

If you do NOT follow the requirements for network coverage, your receive:

Non-Network Benefits4

Mental Health Services

• For Practitioner Services: OptumHealth will considerup to 80 percent of reasonable and customary charges

for covered services after you meet the applicableannual deductible for outpatient practitioner servicesper enrollee, per covered spouse/domestic partner, per all covered dependent children combined5. After the applicable coinsurance maximum is reached per enrollee, per spouse/domesic partner, per all dependent children combined5, the Plan pays up to 100 percent of reasonable and customarycharges for covered services.

• For Approved Facility Services: You are responsiblefor 10 percent coinsurance up to a maximum of$1,500 for you, the enrollee, $1,500 for your enrolledspouse/domestic partner and $1,500 for all enrolleddependent children combined. After the coinsurancemaximum is met, the Plan pays 100 percent of billedcharges for covered services.

Note: The amount you pay for inpatient and outpatientservices does NOT count toward meeting your BasicMedical deductible or Basic Medical and non-networkhospital coinsurance maximum. Deductibles, coinsuranceand maximum coinsurance amounts are separate and notcombined with any other deductible, coinsurance ormaximum coinsurance amounts.

Alcohol/Drug Abuse Services

If you do not call OptumHealth or do not follow theirrecommendations, limited non-network benefits areavailable for medically necessary care. For non-networkcare, you pay a $2,000 deductible for inpatient care perenrollee, per spouse/domestic partner, per all coveredchildren combined; $500 deductible for outpatient careper enrollee, per spouse/domestic partner, per all coveredchildren combined. The Plan then pays 50 percent ofthe network allowance. There are limits on inpatientand outpatient benefits and annual and lifetimemaximums when you use non-network benefits.

The Empire Plan Prescription Drug ProgramUnitedHealthcare/Medco Health Solutions

• When you use a participating retail pharmacy or the mail service pharmacy for up to a 30-day supplyof a covered drug, you pay a $5 copayment forgeneric drugs, $15 copayment for preferred brand-name drugs and $40 copayment for non-preferredbrand-name drugs.

• For a 31- to 90-day supply of a covered drug through a participating retail pharmacy, you pay a $10 copayment for generic drugs, $30 copaymentfor preferred brand-name drugs and $70 copaymentfor non-preferred brand-name drugs.


• For a 31- to 90-day supply of a covered drug throughthe mail service pharmacy, you pay a $5 copaymentfor generic drugs, $20 copayment for preferred brand-name drugs and $65 copayment for non-preferredbrand-name drugs.

• When you fill a prescription for a covered brand-name drug that has a generic equivalent, you pay the non-preferred brand-name copayment plus thedifference in cost between the brand-name drug and its generic equivalent, not to exceed the fullcost of the drug. Exceptions apply. Please contactyour agency HBA for more information.

• The Empire Plan has a flexible formulary (exceptCSEA and Courts) that excludes a small number of brand-name drugs from coverage.

• Prior authorization is required for certain drugs.

• A pharmacist is available 24 hours a day to answerquestions about your prescriptions.

• If you use a non-participating pharmacy, you pay thefull cost and then submit a claim for reimbursementbased on the amount the Program would reimburse aparticipating pharmacy for a covered drug, less theapplicable copayment.

The Empire Plan NurseLineSM

Provides 24-hour access to health information and support.

Empire Plan Benefits Are Available WorldwideThe Empire Plan gives you the freedom to choose aparticipating provider or a non-participating provider.

1 These benefits are subject to medical necessity and to limitations and exclusions described in the Empire Plan Certificateand Empire Plan Reports/Certificate Amendments.

2 If Medicare or another plan provides primary coverage, you receive network benefits for covered services at both network and non-network hospitals.

3 Greater of 10 percent or $75 for outpatient.4 You are responsible for obtaining OptumHealth certification for care obtained from a non-network practitioner or facility. 5 Annual deductibles and coinsurance maximums vary by group. See page 7 for details.

The Empire Plan Centers of Excellence ProgramsThe Centers of Excellence for Cancer Program includes paid-in-full coverage for cancer-related expensesreceived through Cancer Resource Services (CRS). CRS is a nationwide network including many of thenation’s leading cancer centers. The enhanced benefits, including travel reimbursement, are available onlywhen you are enrolled in the Program. (See the Empire Plan Certificate/Reports for details).

The Centers of Excellence for Transplants Program provides paid-in-full coverage for services covered underthe Program and performed at a qualified Center of Excellence. The enhanced benefits, including travelreimbursement, are available only when you are enrolled in the Program and The Empire Plan is your primarycoverage. Precertification is required. (See the Empire Plan Certificate for more information.)

Infertility Centers of Excellence are a select group of participating providers contracted by UnitedHealthcareand recognized as leaders in reproductive medical technology and infertility procedures. Benefits are paid infull, subject to the lifetime maximum benefit of $50,000. A travel allowance is available. Precertification isrequired. (See the Empire Plan Certificate for more information.)

Teletypewriter (TTY) numbers for callers who use a TTY device because of a hearing orspeech disability. All TTY numbers are toll free.

UnitedHealthcare ............................................................................................................TTY only: 1-888-697-9054

Empire BlueCross BlueShield ..........................................................................................TTY only: 1-800-241-6894

OptumHealth...................................................................................................................TTY only: 1-800-855-2881

The Empire Plan Prescription Drug Program...................................................................TTY only: 1-800-759-1089


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Benefits Enrollee Cost

Office Visits $20 per visitNon-Office Hours and Home Visits (by physician) $25 per visit

Specialty Office Visits $20 per visit

Diagnostic/Therapeutic ServicesRadiology $20 per visitLab Tests $20 per visitPathology $20 per visitEKG/EEG $20 per visitRadiation $20 per visitChemotherapy $20 per visit

Women’s Health Care/OB GYNPap Tests $20 per visitMammograms No copaymentPre and Postnatal Visits $20 per visit

(initial visit only)Bone Density Tests $20 per visit

Family Planning Services $20 per visit

Infertility Services $20 per visit

Contraceptive Drugs and DevicesApplicable Rx copayment applies

Emergency Room $50 per visit1

Urgent Care $35 per visit

Ambulance $50 per trip

Outpatient Mental Healthmax 20 visits2 $20 per visit

Inpatient Mental Healthmax 30 days2 No copayment

Outpatient Drug/Alcohol Rehabmax 60 visits $20 per visit

Inpatient Drug/Alcohol Rehabmax 30 days each No copayment


Durable Medical Equipment 20% coinsurance

Prosthetics No copayment

Orthotics No copayment

Rehabilitative Care, Physical, Speech and Occupational Therapy

Inpatient, unlimited No copaymentOutpatient, max 60 consecutive days $20 per visit

Diabetic Supplies $20 per itemInsulin and Oral Agents $20 per item

Hospice, unlimited No copayment

Skilled Nursing Facility, unlimited No copayment

Prescription DrugsRetail, 30-day supply $10/$20/$35Mail Order, 90-day supply $20/$40/$703

Coverage includes contraceptive drugs and devices, injectable and self-injectable medications, fertility drugsand enteral formulas.

Specialty DrugsSpecialty drugs are obtained through Aetna SpecialtyPharmacy, which is our preferred specialty pharmacyprovider for Aetna Pharmacy Management members.Aetna Specialty Pharmacy is wholly owned and operatedby Aetna Inc. As a full-service specialty pharmacy, we donot charge for delivery or dispensing fees for injectables.Specialty drugs dispensed through Aetna SpecialtyPharmacy are subject to our retail and mail orderpharmacy copayment/coinsurance amounts, coveragelimits and exclusions.1 Waived if admitted.2 Biologically based mental illness and coverage for children

with serious emotional disturbance is available beyond this limit as defined by Timothy’s Law.

3 Member communication materials will be mailed to the member upon enrollment explaining the mail order process and how to submit a mail order prescription.


Additional BenefitsDental ..........................................................Not coveredVision4 .........................................................$20 per visit5

Hearing Aids ...............................................Not coveredOut of Area Benefit ..............................While traveling

outside the service area, members are covered foremergency situations only.

Eyeglasses ...........................................Discount ProgramHome Health Care (HHC) unlimited (by HHC agency)....................No copaymentOutpatient Home Health Care unlimited visits per 365-day period6........No copaymentHospice Bereavement Counseling .........No copayment

4 Routine only (including refraction)5 Frequency and age schedules apply6 Four hours of home health aid equals one home care visit.

Plan Highlights for 2009Aetna offers an array of quality benefits and a variety ofspecial health programs for every stage of life: access toextensive provider and hospital networks in our multi-state service areas; emergency care covered worldwide;confidence in knowing that most of Aetna’s matureHMOs have received the distinction of accreditation bythe National Committee for Quality Assurance (NCQA).

Participating PhysiciansServices are provided by local participating physicians in their private offices throughout Aetna’s service area.Participating physicians are not employees of Aetna.

Affiliated HospitalsAetna members are covered at area hospitals to whichtheir Aetna participating physician has admittingprivileges. Aetna members may be directed to otherhospitals to meet special needs.

Pharmacies and PrescriptionsAetna members have access to an extensive network ofparticipating pharmacies in all 50 states, the District ofColumbia, Puerto Rico and the Virgin Islands. Aetnaoffers an incented formulary. Please refer to ourformulary guide at www.aetna.com/formulary forprescriptions that require prior approval.

Medicare CoverageMedicare-primary enrollees are required to enroll inAetna’s Medicare Advantage Plan, The GoldenMedicare Plan.

NYSHIP Code Number 210An IPA HMO serving individuals living or working in Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland,Suffolk, Sullivan and Westchester counties in New York and all counties in New Jersey.

Aetna99 Park AvenueNew York, NY 10016

For information:Customer Service: 1-800-323-9930TTY: 1-800-654-5984Medicare Advantage Customer Service:1-800-282-5366For Pre Enrollment Medicare Information and a Medicare Packet: 1-800-832-2640Web site: www.aetna.com



Office Visits $20 per visitRoutine Adult Physicals $5 per visitPCP visits for sick children to age 19 $5 per visit


Diagnostic/Therapeutic ServicesRadiology $20 per visitLab Tests No copaymentPathology No copaymentEKG/EEG $20 per visitRadiation $20 per visitChemotherapy $20 per visit

Women’s Health Care/OB GYNPap Tests $5 per visitMammograms $5 per visitPre and Postnatal Visits $5 per visit

(first 10 visits only)Bone Density Tests $20 per visit




Emergency Room $50 per visit




Inpatient Mental Healthmax 30 days per year1 No copayment

Outpatient Drug/Alcohol Rehabmax 60 visits per year $20 per visit



Prosthetics 20% coinsurance

Orthotics 20% coinsurance



Inpatient, max 60 days No copaymentOutpatient Rehabilitative Care

max 90 visits $20 per visitOutpatient Physical, Speech and Occupational Therapy

max 30 visits combined $20 per visit



Skilled Nursing Facility, max 120 days No copayment

Prescription DrugsRetail, 30-day supply $10 generic/

$25 preferred/$40 non-preferred2

Mail Order, up to 90-day supply $20 generic/$50 preferred/$80 non-preferred2

There is a separate copayment for each 30-day supplypurchased at a retail pharmacy. You can order up to a 90-day supply through our mail order program with two copayments per 90-day supply. Coverage includescontraceptive drugs and devices and fertility drugs,injectable and self-injectable medications and enteral formulas.

Specialty DrugsDesignated specialty medications are covered only whenpurchased at a participating network specialty pharmacy.Medications purchased from a specialty pharmacy aresubject to the same days supply and cost-sharingrequirements that apply to the retail pharmacy benefit.Mail order does not apply and these medications cannot befilled at mail order. A current list of specialty medicationsand participating specialty pharmacies is available on ourweb site at www.excellusbcbs.com.

1 Biologically based mental illness and coverage for childrenwith serious emotional disturbance is available beyond thislimit as defined by Timothy’s Law.

2 Should a doctor select a brand-name drug when an FDA-approved generic equivalent is available, the member will haveto pay the difference between the cost of the generic and thebrand-name plus any applicable copayments.


Additional BenefitsDental ..........................................................Not coveredVision ...............................$20 copayment for eye exams

associated with disease or injuryHearing Aids

Children to age 19................$600 max, every 3 yearsOut of Area Benefit .................................Our BlueCard®

and Away From Home Care® Program provide routineand urgent care coverage while traveling, for studentsaway at school, members on extended out-of-townbusiness and for families living apart.

Acupuncture, max 10 visits per year...50% coinsuranceOutpatient Surgery Facility .......................$50 per visitPhysician Surgical Copayment ..................$20 per visit

Plan Highlights for 2009With Blue Choice, count on us to deliver the high-quality coverage you want and the value you need. Relyon Blue Choice for discounts on services that encourageyou to develop a healthy lifestyle.• Two copayments for up to a 90-day supply for

prescription drugs through PrimeMail®, our new mail service pharmacy beginning January 1, 2009.

• Well child care is covered in full.• Pay a $5 copayment for PCP visits for sick children

to age 19.• Pay a $5 copayment for preventive services such as

adult routine physicals, mammograms, pap smears and prostate screenings.

Participating PhysiciansWith over 3,200 providers available, Blue Choice offersyou more choice of doctors than any other area HMO. Talk to your doctor about whether Blue Choice is the right plan for you.

Affiliated HospitalsAll operating hospitals in the Blue Choice service areaare available to you. Others outside the service area arealso available. Please call the number to the right for adirectory or check our web site at: www.excellusbcbs.com.

Pharmacies and PrescriptionsBlue Choice members may have their prescriptions filled at any of our over 60,000 participating pharmaciesnationwide. Simply show the pharmacist your ID card.Blue Choice offers an incented formulary. CallPrimeMail® at 1-866-260-0487 for mail orderprescriptions. Fertility, injectable and self-injectableprescription drugs are covered.

Medicare CoverageMedicare-primary enrollees are required to enroll in Medicare Blue Choice, the Excellus BlueCrossBlueShield Medicare Advantage Plan. To qualify, you must be enrolled in Medicare Parts A and B and live in one of the counties listed below. Once youbecome eligible for Medicare, some of your MedicareBlue Choice copayments will vary from the copaymentsof NYSHIP-primary enrollees. Please call the MedicareBlue Choice number below for further details.

NYSHIP Code Number 066A Network HMO serving individuals living or working in Livingston, Monroe, Ontario, Seneca,Wayne and Yates counties.

Blue Choice165 Court StreetRochester, NY 14647

For information:Blue Choice: 585-454-4810 or 1-800-462-0108TTY: 1-877-398-2282Medicare Blue Choice: 1-877-883-9577Web site: www.excellusbcbs.com



Office Visits $20 per visitAnnual Adult Routine Physicals No copaymentAnnual Gynecological Exams No copayment


Diagnostic/Therapeutic ServicesRadiology $20 per visit1

Lab Tests $20 per visit1

Pathology $20 per visit1

EKG/EEG $20 per visitRadiation $20 per visitChemotherapy $20 per visit

Women’s Health Care/OB GYNPap Tests No copaymentMammograms No copaymentPre and Postnatal Visits No copaymentBone Density Tests $20 per visit







Outpatient Mental Health, max 20 visits (individual and group combined)2 $20 per visit

Inpatient Mental Healthmax 30 days per calendar year2 No copayment





Orthotics3 50% coinsurance



Inpatient, max 60 days No copaymentOutpatient Short-term Physical and Occupational Therapy

max 30 visits each per calendar year $20 per visitOutpatient Short-term Speech Therapy

max 20 visits per calendar year $20 per visit

Diabetic SuppliesRetail, up to 30-day supply $15 per itemMail Order, up to 90-day supply

Two and a half copaymentsInsulin and Oral Agents

Retail, up to 30-day supply $15 per itemMail Order, up to 90-day supply

Two and a half copayments

Hospice, max 210 days No copayment



$25 formulary brand/$40 non-formularyMail Order, 90-day supply Two and a half copayments

Coverage includes contraceptive drugs and devices,injectable and self-injectable medications, fertility drugsand enteral formulas. Over-the-counter drugs listed onCDPHP’s formulary are subject to the generic copayment.

Specialty DrugsCertain specialty prescriptions require prior approval, are subject to clinical management programs and must be filled by a CDPHP-participating specialty pharmacyvendor. It is easy to contact Caremark Specialty PharmacyServices at 1-800-237-2767. A representative will collectyour information, coordinate with your doctor andCDPHP and arrange delivery of your medications. Formore information, visit Rx Corner at www.cdphp.com.Specialty drugs are subject to the same copayment tiers as other prescription drugs.

1 No copayment for specific diagnostic services at preferredradiology or designated laboratory sites.



3 Excludes shoe inserts.

Additional BenefitsDental ..........................................................Not coveredVision...........................................................Not coveredHearing Aids ...............................................Not coveredOut of Area Benefit ...................................Coverage for

emergency care out-of-area. College students are alsocovered for pre-approved follow-up care.

Allergy Injections....................................No copaymentOutpatient Surgery Facility .......................$75 per visitDiabetes Self-management Education .......$20 per visitGlucometer .................................................$15 per item

Plan Highlights for 2009CDPHP ranked among the top 25 plans in the nationaccording to U.S. News & World Report/NCQAAmerica’s Best Health Plans 2007. Our dedicated memberservices representatives are available to respond to yourquestions Monday through Friday, 8 a.m. to 8 p.m. Ourcommitment goes beyond providing first-rate customerservice. We want to help you remain healthy and assistyou in reaching your wellness goals. To help you achievethis, as a CDPHP member, you can take advantage of avast array of free wellness classes, including MediterraneanCooking, Intro to Mat Pilates, Belly Dancing and manymore. Continue to watch for SmartMoves, a quarterlynewsletter providing you with CDPHP updates as well as tips on ways to improve your health. Do you havequestions on an upcoming surgery or need advice onmanaging your diabetes or asthma? Contact a healthcoach 24/7 through Health Coach Connection. Enroll in our Weigh 2 Be Program and receive 50% after acompleted 10-week Weight Watchers session.

Participating PhysiciansCDPHP is now affiliated with more than 10,000participating practitioners and providers.

Affiliated HospitalsCDPHP is proud to be affiliated with most majorhospitals within our service area. Members are cared forwithin the CDPHP network, unless an out-of-networkfacility or a Center of Excellence is approved for specialcare needs.

Pharmacies and PrescriptionsCDPHP offers an incented formulary. Prescriptions maybe filled nationwide at any participating pharmacy. RxCorner at www.cdphp.com enables members to log in andview claims history and research cost-saving alternatives.Save money by using mail order. Find forms online or callMember Services at 518-641-3700 or 1-800-777-2273.Certain prescriptions require prior approval and specialtydrugs for a few serious conditions are subject to clinicalmanagement programs and must be delivered by aCDPHP-participating specialty pharmacy vendor.

Medicare CoverageMedicare-primary enrollees must enroll in CDPHP’sMedicare Advantage Plan, the Group Medicare ChoicesHMO plan. You must be enrolled in Medicare Parts A andB to qualify. For further details, please see Choices for 2009for Retirees of New York State and Participating Employers.

NYSHIP Code Number 063An IPA HMO serving individuals living or workingin Albany, Columbia, Fulton, Greene, Montgomery,Rensselaer, Saratoga, Schenectady, Schoharie,Warren and Washington counties.

NYSHIP Code Number 300An IPA HMO serving individuals living or working in Broome, Chenango, Delaware, Essex,Hamilton, Herkimer, Madison, Oneida, Otsego and Tioga counties.

NYSHIP Code Number 310An IPA HMO serving individuals living or workingin Dutchess, Orange and Ulster counties.

Capital District Physicians’ Health Plan, Inc.(CDPHP)500 Patroon Creek BoulevardAlbany, NY 12206-1057

For Information:Member Services: 518-641-3700 or 1-800-777-2273TTY: 1-877-261-1164Web site: www.cdphp.com



Office Visits $10 per visitWell Child Care No copayment


Diagnostic/Therapeutic ServicesRadiology $10 per visitLab Tests No copayment1

Pathology No copaymentEKG/EEG $10 per visitRadiation $10 per visitChemotherapy $10 per visit

Women’s Health Care/OB GYNPap Tests No copaymentMammograms No copaymentPre and Postnatal Visits No copayment2

Bone Density Tests $10 per visit


Infertility Services $10 per visit3

Contraceptive Drugs and DevicesApplicable Rx copayment applies4





Inpatient Mental Health max 30 days5 No copayment

Outpatient Drug/Alcohol Rehab max 60 visits $10 per visit

Inpatient Drug/Alcohol Rehab max 30 days each No copayment






Inpatient, max 45 days No copaymentOutpatient, max 20 visits $10 per visit




Prescription Drugs Retail, 30-day supply $5 generic/

$15 formulary brand/$35 non-formularyMail Order, 90-day supply $15 generic/

$45 formulary brand/$105 non-formularyCoverage includes contraceptive drugs and devices,prenatal vitamins and vitamins with fluoride, fertility drugs, injectable/self-injectable medications, enteralformulas, insulin and oral diabetic agents. Mostinjectable drugs are subject to prior approval. Membercommunication materials will be mailed to the memberupon enrollment explaining the mail order process andhow to submit a mail order prescription.

Specialty DrugsSpecialty drugs are available through mail order at theapplicable copayment.

1 For services at a stand-alone lab (must use Quest) oroutpatient hospital that participates as a Quest Diagnosticshospital draw site. Lab services performed in conjunctionwith outpatient surgery or an emergency room visit will alsobe paid in full.

2 $10 copayment will only be taken on the initial office visitto confirm the pregnancy.

3 For services to diagnose and treat infertility.4 Approved generic oral contraceptives covered at 100%.5 Biologically based mental illness and coverage for children

with serious emotional disturbance is available beyond thislimit as defined by Timothy’s Law.


Additional BenefitsDental6 .......................20% discount at select providers,

free second annual examVision ...................VisionPLUS Program (details below)Hearing Aids ...............................................Not coveredOut of Area Benefit .......................Worldwide coverage

for emergency and urgent care through the BlueCardprogram, a network of BlueCross and BlueShieldproviders across the country and around the world.Guest membership for routine care away from homethat enables members on extended business trips orfamily members away at school to join a nearby BlueHMO and enjoy the same benefits they do at home.

VisionPLUS program ..........Community Blue members are entitled to a complete eyecare program thatincludes routine eye exams and discounts fromparticipating VisionPLUS providers. Discountsincluded on frames, lenses, contact lenses and supplies.

Artificial Insemination ......................20% coinsurance7

6 Preventive7 Other artificial means to induce pregnancy (in-vitro, embryo

transfer, etc.) are not covered.

Plan Highlights for 2009Innovative wellness and health management programsthat offer discounts on acupuncture, massage therapy,nutritional counseling, fitness centers and spas. Membershave access to a patient advocacy program, HealthAdvocate, which assists patients with locating providers,scheduling appointments and a variety of other services.

Participating PhysiciansCommunity Blue has over 3,000 physicians and healthcare professionals in our network who see patients intheir private offices throughout our service area.

Affiliated HospitalsCommunity Blue contracts with all Western New Yorkhospitals to provide health care services to our members.Community Blue members may be directed to otherhospitals to meet special needs when medically necessary.

Pharmacies and PrescriptionsCommunity Blue members may obtain prescriptionsfrom a nationwide network of nearly 45,000participating pharmacies. Prescriptions are filled for up to a 30-day supply (including insulin) when filled at a participating pharmacy. Member’s copayment willreflect $5 formulary generic, $15 formulary brand, $35 non-formulary prescriptions. Community Blue offers an incented formulary.

Medicare CoverageMedicare-primary enrollees are required to enroll inSenior Blue, the Community Blue Medicare AdvantagePlan. To qualify you must be enrolled in Medicare PartsA and B and live in one of the counties listed below.

NYSHIP Code Number 067An IPA HMO serving individuals living or working in Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming counties.

Community BlueThe HMO of BlueCross BlueShield of Western New YorkP.O. Box 80Buffalo, NY 14240-0080

For information:Buffalo: 716-887-8840 or 1-877-576-6440Olean: 716-376-6000 or 1-800-887-8130Jamestown: 716-484-1188 or 1-800-944-2880TTY: 1-888-249-2583Web site: www.bcbswny.com



Office Visits $20 per visit


Diagnostic/Therapeutic ServicesRadiology No copaymentLab Tests No copaymentPathology No copaymentEKG/EEG No copaymentRadiation No copaymentChemotherapy No copayment

Women’s Health Care/OB GYNPap Tests No copaymentMammograms No copaymentPre and Postnatal Visits No copaymentBone Density Tests No copayment






Ambulance No copayment

Outpatient Mental Health2

max 20 visits3 $20 per visit

Inpatient Mental Health2

max 30 days3 No copayment

Outpatient Drug/Alcohol Rehab2

max 60 visits No copayment

Inpatient Drug/Alcohol Rehab2

max 30 days each No copayment

Durable Medical Equipment No copayment





Inpatient, max 30 days No copaymentOutpatient Physical Therapy, max 30 visits combined

Home or Office $20 per visitOutpatient Facility No copayment

Outpatient Speech/Language, Occupational and Vision Therapy, max 30 visits combined

Home or Office $20 per visitOutpatient Facility No copayment

Diabetic Supplies No copayment when obtained through EBCBS’s medical supply vendor.When obtained through a pharmacy, supplies are subjectto the applicable prescription drug copayments.

Insulin and Oral AgentsApplicable Rx copayment applies



Prescription DrugsRetail, 30-day supply $10 generic/$20 brand/

$40 non-formulary per prescriptionMail Order, 90-day supply $20 generic/$40 brand/

$80 non-formulary per prescriptionMore information available under Pharmacies and Prescriptions.

Specialty DrugsSpecialty medications are only dispensed in 30-daysupply. Enrollees are required to pay the applicablecopayment for each 30-day supply.

1 Waived if admitted within 24 hours.2 Precertification is required.3 Biologically based mental illness and coverage for children


Empire BlueCross BlueShield HMO


Additional BenefitsDental ..........................................................Not coveredVision...........................................................Not coveredHearing Aids ...............................................Not coveredOut of Area Benefit ...................................Coverage for

members traveling outside the service area may beavailable through the Guest Membership and/orBlueCard Programs. Guest Membership offerstemporary coverage through the local BlueCrossand/or BlueShield HMO plan. Contract holders areeligible for Guest Membership if away from home formore than 90 days, but less than 180 days. Full-timestudents and other eligible dependents are eligible for Guest Membership if away from home for morethan 90 days. Coverage is available through theBlueCard Program for an enrollee traveling outside of the service area who may encounter an urgent oremergent situation and is not enrolled in the GuestMembership Program.

Plan Highlights for 2009Empire BlueCross BlueShield HMO provides New YorkState employees located in our 28-county service area witha full range of benefits that include low out-of-pocket costs.Visit our state-of-the-art web site, www.empireblue.com,where your personal healthcare information is yours tomanage any time of the day or night. You will instantly be able to find a list of your claims and payment status, e-mail messages, your personal profile and healthcareprovider information. Empire BlueCross BlueShield HMOearned the highest level of accreditation (Excellent) fromthe National Committee for Quality Assurance (NCQA).

Participating PhysiciansEmpire BlueCross BlueShield HMO provides access to a network of over 65,000 provider locations.

Affiliated HospitalsEmpire BlueCross BlueShield HMO members arecovered through a comprehensive network of areahospitals (over 140) throughout our 28-county operatingarea to which their participating physician has admittingprivileges. HMO members may be directed to otherhospitals to meet special needs. Our provider directory and web site contain a list of all participating hospitals,including New York City hospitals.

Pharmacies and PrescriptionsEnrollees with prescription coverage can use local andnational pharmacies. Members who use our mail servicepay only two copayments for each 90-day supply ofmedication; a 33% savings over filling 90-day prescriptionsat the retail level. Coverage includes contraceptive drugsand devices, injectable and self-injectable drugs, fertilitydrugs and enteral formulas. Empire BlueCross BlueShieldHMO offers an incented formulary.

Medicare CoverageEmpire BlueCross BlueShield HMO coordinates coveragewith Medicare and offers the same benefits to NYSHIPMedicare eligibles.

NYSHIP Code Number 280An IPA HMO serving individuals living or working in Albany, Clinton, Columbia, Delaware,Essex, Fulton, Greene, Montgomery, Rensselaer,Saratoga, Schenectady, Schoharie, Warren andWashington counties.

NYSHIP Code Number 290An IPA HMO serving individuals living or working in Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk andWestchester counties.

NYSHIP Code Number 320An IPA HMO serving individuals living or working in Dutchess, Orange, Putnam, Sullivan and Ulster counties.

Empire BlueCross BlueShield HMO11 Corporate Woods BoulevardP.O. Box 11800Albany, NY 12211-0800

For information:Empire BlueCross BlueShield HMO:1-800-453-0113TTY: 1-800-241-6894Web site: www.empireblue.com

Services provided by Empire HealthChoice HMO, Inc., an independent licensee of the BlueCross and BlueShield Association.



Office VisitsDependent Children 0-18 No copaymentAdults $20 per visit

Specialty Office Visits1

Dependent Children 0-18 No copaymentAdults $20 per visit


Lab Tests No copayment2

Pathology No copayment2

EKG/EEG No copayment2

Radiation No copayment2

Chemotherapy No copayment2

Women’s Health Care/OB GYNPap Tests No copaymentMammograms No copaymentPre and Postnatal Visits No copaymentBone Density Tests $20 per visit





Urgent Care $35 per visit2

Ambulance $50 per trip2

Outpatient Mental Healthmax 20 visits3 $20 per visit2


Outpatient Drug/Alcohol Rehabmax 60 visits $20 per visit2







Inpatient, max 60 days No copaymentOutpatient, max 30 visits combined $20 per visit2

Diabetic Supplies $20 per item2

Insulin and Oral AgentsRetail, 30-day supply $20 per itemMail Order, 90-day supply $40 per item


Skilled Nursing Facilitymax 120 days per year No copayment


$20 preferred brand/$30 non-preferred brandMail Order, 90-day supply $20 generic/

$40 preferred brand/$50 non-preferred brandCoverage includes contraceptive drugs and devices,injectable and self-injectable medications, fertilitydrugs and enteral formulas.

Specialty DrugsSpecialty drugs are defined as injectable and non-injectable drugs that require frequent dosing amounts,intensive clinical monitoring or specialized producthandling. Members are required to pay the copaymentfor each 30-day supply of specialty medication. No mailorder benefit is available for specialty drugs.

1 No Primary Care Physician (PCP) referral required for GHIHMO participating providers.

2 Copayment applies to all covered dependents.3 Biologically based mental illness and coverage for children



Additional BenefitsDental ..........................................................Not coveredVision4..........................................$20 per exam per yearHearing Aids ...............................................Not coveredOut of Area Benefit .....................................If you are out

of the GHI HMO service area and experience amedical emergency, go to the nearest emergencyfacility for services. To receive non-emergent care,your PCP or the on-call physician must authorizeyour care as appropriate. In the event you are unableto reach your PCP, call GHI HMO Customer ServiceDepartment at 1-877-2GHI-HMO (1-877-244-4466)24 hours a day, 7 days a week.

4 Routine only

Plan Highlights for 2009No PCP referrals required for GHI HMO participatingproviders. Since 1937, GHI has been building astatewide reputation for strength, stability and anextraordinary commitment to prompt, responsiveservice. As the largest not-for-profit health insurer inNew York State, GHI introduced the GHI HMO in1999. GHI HMO’s provider network is available in 28 counties in New York State. GHI HMO’s primaryconcern is to provide medical coverage that givesmembers confidence that they and their families are well covered. With more than three million statewidemembers, GHI is committed to providing individuals,families and businesses with access to affordable, qualityhealthcare, supported by outstanding customer service.

Participating PhysiciansServices are provided by participating physicians in theirprivate offices. GHI HMO has over 21,000 memberphysicians and health care professionals throughout 28counties in New York State. Please note: To enroll in GHI,NYSHIP members must live or work in one of the 15NYSHIP-approved counties, however, once enrolled, theymay use providers throughout GHI’s 28-county service area.

Affiliated HospitalsGHI HMO members are covered at area hospitals to which their GHI HMO physician has admittingprivileges. GHI HMO members may be directed to other hospitals based on medical necessity when prior approval is obtained and the care is deemedappropriate by a GHI HMO Medical Director.

Pharmacies and PrescriptionsGHI HMO offers an incented formulary. Members mayutilize any GHI HMO pharmacy for retail prescriptiondrugs up to a 30-day supply. If a brand-name drug isselected or prescribed and there is a generic equivalentavailable, the member pays the brand copayment and the difference in price between the generic and the branddrug. All maintenance medication is obtained through the mail order program. For a complete list of prescriptionscovered under our formulary, or for a list of prescriptionsthat require prior approval, go to www.ghi.com and clickon “Pharmacy Plan” under Our Plans. For informationregarding mail order drug benefits, or to set up your mailorder account, contact Medco at 1-866-544-3772.

Medicare CoverageGHI HMO offers the same benefits to NYSHIP Medicareeligibles. GHI HMO coordinates coverage with Medicare.

NYSHIP Code Number 220An IPA HMO serving individuals living or working in Albany, Columbia, Delaware, Greene,Rensselaer, Saratoga, Schenectady, Warren andWashington counties.

NYSHIP Code Number 350An IPA HMO serving individuals living or working in Dutchess, Orange, Putnam, Rockland,Sullivan and Ulster counties.

GHI HMO789 Grant AvenueLake Katrine, NY 12449orGHI HMOP.O. Box 4181Kingston, NY 12401

For information:Kingston: 1-877-244-4466TTY: 1-877-208-7920Web site: www.ghi.com





Diagnostic/Therapeutic ServicesRadiology No copaymentLab Tests No copaymentPathology No copaymentEKG/EEG No copaymentRadiation No copaymentChemotherapy No copayment

Women’s Health Care/OB GYNPap Tests No copaymentMammograms No copaymentPre and Postnatal Visits No copaymentBone Density Tests No copayment


Infertility Services1 $5 per visit





Outpatient Mental Healthmax 20 visits2 No copayment





Durable Medical Equipment No copayment




Inpatient, max 30 days No copaymentOutpatient, max 90 visits combined $5 per visit

Diabetic Supplies $5 per monthInsulin and Oral Agents $5 per month


Skilled Nursing Facility, unlimited No copayment

Prescription DrugsRetail, 30-day supply $5Mail Order, 90-day supply $7.50

Subject to drug formulary, coverage includescontraceptive drugs and devices, fertility drugs, injectableand self-injectable medications and enteral formulas.Copayments are reduced by 50% when utilizing the HIPmail order service. Up to a 90-day supply of generic orbrand-name drugs may be obtained.

Specialty DrugsCoverage is provided through HIP’s “Specialty PharmacyProgram”. Specialty drugs include injectables and oralagents that are more complex to administer, monitor andstore in comparison to traditional drugs. Specialty drugsmay require prior approval, which can be obtainedthrough HIP Pharmacy Services by the HIP prescribingphysician. Specialty drugs are subject to the applicableRx copayment and Rx formulary.

1 Includes the supplies and drugs related to the diagnosis andtreatment of infertility.



Additional BenefitsDental ..........................................................Not coveredVision3 .....................................................No copaymentHearing Aids ...............................................Not coveredOut of Area Benefit .....................Members are covered

for emergency care both in and outside the HMOservice area as well as with participating providersand non-participating providers.

Eyeglasses ....................................................$45 per pair; one pair every 24 months from selected frames

Laser Vision Correction (LASIKS) ...Discount ProgramFitness Program .................................Discount ProgramAlternative Medicine Program .........Discount ProgramArtificial Insemination .................................$5 per visitProstate Cancer Screening...........................Included in

office visit copaymentDialysis Treatment......................................$10 per visit

3 Routine only

Plan Highlights for 2009HIP’s network has expanded to over 28,500 providers in more than 48,000 locations. Plus, HIP offers morethan 60 years of experience caring for union membersand has the support of the New York State CentralLabor Council. Our web site, hipusa.com®, is availablein English, Spanish, Chinese and Korean.

Participating PhysiciansHIP offers the diversified choice of a traditional networkof independent physicians who see patients in their ownoffices as well as providers in physician group practicesthat offer most, if not all of a member’s medical needsunder one roof. Group practices offer services in mostmajor specialties such as cardiology, ophthalmology andorthopedics, as well as ancillary services like lab tests, X-rays and pharmacy services.

Affiliated HospitalsHIP members have access to 108 of the area’s leadinghospitals, including major teaching institutions.

Pharmacies and PrescriptionsFilling a prescription is easy with HIP’s network of over 40,000 participating pharmacies nationwide,including over 4,700 participating pharmaciesthroughout New York State. HIP also has a mail orderprogram through Medco Health Solutions, Inc. HIP offers a closed formulary.

Medicare CoverageHIP offers two plans to NYSHIP retirees. Retirees whoare not Medicare-eligible are offered the same coverageas active employees. Medicare-primary retirees arerequired to enroll in HIP VIP Premier Medicare Plan, a Medicare Advantage Plan that provides Medicarebenefits and more.

NYSHIP Code Number 050A Network HMO serving individuals living orworking in Bronx, Kings, Nassau, New York, Queens,Richmond, Suffolk and Westchester counties.

HIP Health Plan of New York55 Water StreetNew York, NY 10041

For information:1-877-861-0175TTY: 1-888-447-4833Web site: hipusa.com





Diagnostic/Therapeutic ServicesRadiology $40 per visitLab Tests $25 per visitPathology $25 per visitEKG/EEG $40 per visitRadiation $25 per visitChemotherapy $25 per visit

Women’s Health Care/OB GYNPap Tests $10 per visitMammograms $10 per visitPre and Postnatal Visits $5 per visit

(first 10 visits only)Bone Density Tests $25 per visit

Family Planning Services $25 per visit PCP/$40 per visit specialist

Infertility Services Applicable copayment applies





Outpatient Mental Healthmax 20 visits per calendar year1 $40 per visit









Inpatient, max 60 days No copaymentOutpatient Physical, Speech, Occupational and Respiratory Therapy


Diabetic Supplies, 30-day supply $25 per itemInsulin and Oral Agents, 30-day supply $25 per item



Prescription DrugsRetail, 30-day supply $10 Tier One/

$30 Tier Two/$50 Tier Three2

Mail Order, 90-day supply $20 Tier One/$60 Tier Two/$100 Tier Three2

Coverage includes contraceptive drugs and devices,injectable and self-injectable medications, fertility drugsand enteral formulas.

Specialty DrugsSpecialty medications after the initial first fill must be purchased from one of our participating specialtypharmacies.


2 Should a doctor select a brand-name drug (Tier Two or Tier Three) when an FDA-approved generic equivalent isavailable, the benefit will be based on the generic drug’s costand the member will have to pay the difference, plus anyapplicable copayments. If your prescription has no approvedgeneric available, your benefit will not be affected.

Additional BenefitsDental ..........................................................Not coveredVision ...........................................................$40 per visit

for eye exams associated with disease or injuryHearing Aids ......................................Children to age 19,

$600 maximum, every three years


Out of Area Benefit .................................Our BlueCard®

and Away From Home Care® Program provide routineand urgent care coverage while traveling, for studentsaway at college, members on extended out-of-townbusiness and families living apart.

Hearing Exam ...........................$40 per visit for routine(once every 12 months); $40 per visit for diagnostic

SurgeryPhysician-inpatient................................lesser of $200

copayment or 20% coinsurancePhysician-outpatient at a hospital, facility or surgery center .....................$40 copaymentPhysician’s office ...................lesser of $50 copayment

or 20% coinsuranceSurgical Care (Facility) ..........................$50 copaymentMaternity

(Physician charge for delivery) .............lesser of $200copayment or 20% coinsurance

Plan Highlights for 2009• With HMOBlue 25, members have access to area

providers from 24 counties in our service area.• Well child care is covered in full.• Pay a $10 copayment for routine preventive services

such as adult physicals, mammograms, pap smears,prostate screenings and routine adult immunizations.

• Two copayments for a 90-day prescription drug supplythrough our mail order program.

• Our BlueCard® and Away From Home Care® Programprovide routine and urgent care coverage whiletraveling, for students away at college, members onextended out-of-town business or families living apart.

• Our Member Discount program provides discounts onhealthy programs and services.

• Our web site makes it easy to do business with us, whenit is convenient for you, 24 hours a day, 7 days a week.

Participating PhysiciansHMOBlue is affiliated with more than 4,700 physiciansand health care professionals.

Affiliated HospitalsAll hospitals within our designated service area participatewith HMOBlue. Members may be directed to otherhospitals to meet special needs when medically necessary.

Pharmacies and PrescriptionsHMOBlue members may purchase prescription drugs at any participating pharmacy in the FLRx Network.This network has over 60,000 pharmacies nationwide.Specialty medications after the initial fill must bepurchased from one of our participating specialtypharmacies. HMOBlue offers an incented formulary.

Medicare CoverageHMOBlue offers the same benefits to NYSHIP Medicareeligibles. HMOBlue coordinates coverage with Medicare.

NYSHIP Code Number 072An IPA HMO serving individuals living or working in Broome, Cayuga, Chemung, Cortland,Onondaga, Oswego, Schuyler, Steuben, Tioga andTompkins counties.

HMOBlueExcellus BlueCross BlueShieldCentral New York RegionP.O. Box 22999Rochester, NY 14692

For information:1-800-447-6269TTY: 1-877-398-2275Web site: www.excellusbcbs.com

NYSHIP Code Number 160An IPA HMO serving individuals living or working inChenango, Clinton, Delaware, Essex, Franklin, Fulton,Herkimer, Jefferson, Lewis, Madison, Montgomery,Oneida, Otsego and St. Lawrence counties.

HMOBlueExcellus BlueCross BlueShieldUtica Region12 Rhoads DriveUtica, NY 13502

For information:1-800-722-7884TTY: 1-877-398-2275Web site: www.excellusbcbs.com





Diagnostic/Therapeutic ServicesRadiology $15 per visitLab Tests No copaymentPathology No copaymentEKG/EEG $10 per visitRadiation $15 per visitChemotherapy $10 per visit

Women’s Health Care/OB GYNPap Tests $10 per visitMammograms No copaymentPre and Postnatal Visits No copaymentBone Density Tests $15 per visit







Outpatient Mental Healthmax 20 visits per calendar year; unlimited ifbiologically based diagnosis or child with serious emotional disorder2 $10 per visit

Inpatient Mental Healthmax 30 days per calendar year; unlimited if biologically based diagnosis or child with serious emotional disorder2 No copayment






Orthotics3 No copayment


Inpatient, max 45 days No copaymentOutpatient, up to 20 visits

combined per year $15 per visit

Diabetic SuppliesRetail, 30-day supply $10 per itemMail Order Not available

Insulin and Oral Agents $10 or applicable pharmacy rider, whichever is less



Prescription DrugsRetail, 30-day supply $5 tier I, most generic drugs/

$15 tier II, most preferred brand-name drugs/$30 tier III, all other drugs

Mail Order Not availableCoverage includes contraceptive drugs and devices,injectable and self-injectable medications, fertility drugsand enteral formulas. Tier I oral contraceptives coveredin full.

Specialty Drugs Not available

1 Within the service area. Outside the service area - $10copayment plus the difference in cost between IndependentHealth’s payment and the provider’s charges, if any. $35 pervisit to a participating After Hours Care Facility.


3 Excludes shoe inserts.


Additional BenefitsDental4....................$50 per cleaning and 20% discount

on additional services at select providersVision5 ....................$10 per visit once every 12 monthsHearing Aids......Discounts available at select locationsOut of Area Benefit ..............................While traveling


Home Health Care, max 40 visits ..............$10 per visitEyeglass lenses...........................$35/single vision lenses

Frames 50% off retail up to $130 andmember pays 80% of balance over $130

Urgent Care in Service Areafor After Hours Care .................................$35 per visit

4 Preventive5 Routine only

Plan Highlights for 2009Independent Health has led the way in providingWestern New York with innovative solutions that setthe standard for quality and service for health plans.We’ve consistently earned top ratings from NCQA,which is why you can feel comfortable and confidentchoosing us for your health coverage needs.

Participating PhysiciansIndependent Health is affiliated with over 3,000physicians and health care providers throughout the eight counties of Western New York.

Affiliated HospitalsIndependent Health members are covered at all WesternNew York hospitals to which their physicians haveadmitting privileges. Members may be directed to otherhospitals when medically necessary.

Pharmacies and PrescriptionsOver 350 pharmacies including many national chains.Members may obtain prescriptions out of the servicearea by using our National Pharmacy Network.Independent Health offers an incented formulary.

Medicare CoverageIndependent Health Medicare-primary retirees mustenroll in Medicare Encompass, a Medicare AdvantagePlan. Copayments will differ from the copayments of aNYSHIP-primary enrollee. Call for detailed information.

NYSHIP Code Number 059An IPA HMO serving individuals living or workingin Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming counties.

Independent Health511 Farber Lakes Dr.Buffalo, NY 14221

For information:Customer Service: 1-800-501-3439TTY: 716-631-3108Web site: www.independenthealth.com





Diagnostic/Therapeutic ServicesRadiology $20 per visitLab Tests No copaymentPathology No copaymentEKG/EEG No copaymentRadiation $20 per visitChemotherapy $20 per visit

Women’s Health Care/OB GYNPap Tests $20 per visitMammograms No copayment1

Pre and Postnatal Visits $20 per visit(initial visit only)

Bone Density Tests $20 per visit
















Inpatient, max 2 months No copaymentOutpatient Physical, Speech and Occupational Therapy


Diabetic Supplies$20 copayment per boxed item for a 31-day supply

Insulin and Oral Agents$20 copayment per boxed item for a 31-day supply


Skilled Nursing Facilitymax 45 days No copayment


$30 brand/$50 non-formularyMail Order, 90-day supply $20 generic/

$60 brand/$100 non-formularyCoverage includes fertility, injectable and self-injectablemedications, contraceptive drugs and devices and enteralformulas subject to the limitations listed above and inyour certificate of coverage.

Specialty DrugsMVP uses CuraScript, a specialty pharmacy servicescompany. Specific copayments are listed above. Refer towww.curascript.com for additional information.

1 In a hospital setting. $20 per visit in an office setting.2 Biologically based mental illness and coverage for children



Additional BenefitsDental...........................$25 per visit, children to age 19Vision3 .....................................$20 per exam/24 monthsHearing Aids ...............................................Not coveredOut of Area Benefit ..............................While traveling


3 Routine only

Plan Highlights for 2009No referrals required! See any specialist in the MVPnetwork without a referral. As an MVP member, youcan enjoy significant savings on a wide variety of health-related items, plus special discounts on LASIKEye Surgery, Alternative Medicine and Health andFitness Centers!New for 2009! Each subscriber is eligible to bereimbursed for up to $50 per year for health and wellnessactivities. Claim forms are available on our web sitewww.mvphealthcare.com. Simply submit the receipt foryour activity with a claim form for reimbursement.

Participating PhysiciansMVP Health Care provides services through more than27,500 participating physicians and health practitionerslocated throughout its service area.

Affiliated HospitalsMVP members are covered at participating areahospitals to which their MVP physician has admittingprivileges. MVP members may be directed to otherhospitals to meet special needs when medicallynecessary upon prior approval from MVP.

Pharmacies and PrescriptionsVirtually all pharmacy “chain” stores and manyindependent pharmacies within the MVP service areaparticipate with the MVP prescription drug program.Also, MVP offers convenient mail order service for selectmaintenance drugs. MVP offers an incented formulary.

Medicare CoverageMedicare-primary enrollees located in the East Region(060) and the Central Region (330) must enroll in the MVP Gold Plan, MVP Health Care’s MedicareAdvantage Plan. Some of the MVP Gold Plan’scopayments may vary from the MVP HMO Plan’scopayments. Please contact our member servicesdepartment for further details. The MVP HMO plan coordinates coverage with Medicare in the Mid-Hudson Region (340) and the North Region (360).

NYSHIP Code Number 060 (East)An IPA HMO serving individuals living or workingin Albany, Columbia, Fulton, Greene, Hamilton,Montgomery, Rensselaer, Saratoga, Schenectady,Schoharie, Warren and Washington counties.

NYSHIP Code Number 330 (Central)An IPA HMO serving individuals living or workingin Broome, Cayuga, Chenango, Cortland, Delaware,Herkimer, Jefferson, Lewis, Madison, Oneida,Onondaga, Oswego, Otsego and Tioga counties.

NYSHIP Code Number 340 (Mid-Hudson)An IPA HMO serving individuals living or working in Dutchess, Orange, Putnam, Rockland, Sullivan and Ulster counties.

NYSHIP Code Number 360 (North)An IPA HMO serving individuals living or working in Franklin and St. Lawrence counties.

MVP Health CareP.O. Box 2207625 State StreetSchenectady, NY 12301-2207

For information:Customer Service: 1-888-MVP-MBRS (687-6277)TTY: 1-800-662-1220Web site: www.joinmvp.com



Office Visits $20 per visitPCP Sick Visits

Children age 0-4 No copaymentChildren age 5-18 $10 per visit


Diagnostic/Therapeutic ServicesRadiology $20 per visitLab Tests $5 per dayPathology $5 per dayEKG/EEG $20 per visitRadiation No copaymentChemotherapy $20 per visit

Women’s Health Care/OB GYNPap Tests $15 per visitMammograms No copaymentPre and Postnatal Visits

$50 copayment per pregnancyBone Density Tests $20 per visit



Contraceptive Drugs and Devices No copayment




Outpatient Mental Health, individual or groupmax 20 visits each1 $20 per visit









Inpatient, unlimited No copaymentOutpatient, max 30 visits combined $20 per visit

Diabetic SuppliesRetail, 30-day supply $20 per itemMail Order, 90-day supply $50 per item

Insulin and Oral AgentsRetail, 30-day supply $20 per itemMail Order, 90-day supply $50 per item


Skilled Nursing Facilitymax 120 days/year; 360 days/life No copayment

Prescription DrugsRetail, 30-day supply $10 Tier 1/

$30 Tier 2/$50 Tier 3Mail Order, up to 90-day supply $20 Tier 1/

$60 Tier 2/$100 Tier 3If a member requests a brand-name drug to theprescribed generic drug, he/she pays the differencebetween the cost of the generic and the brand-name plusthe Tier 1 copayment. Coverage includes fertility drugs,injectable and self-injectable medications and enteralformulas. Approved prescription generic contraceptivedrugs and devices and those without a generic equivalentare covered at 100% under retail and mail order.

Specialty DrugsPreferred Care works with CuraScript, a specialtypharmacy services company that provides specialtyinjectable medications to our members with chronicconditions to maximize their medication management.Prescriptions are delivered by next-day service to themember’s home or office. Refer to www.curascript.comfor additional information.



Additional BenefitsDental ..........................................................Not coveredVision .......................................$20 per visit for routine;

$20 per visit for diagnosticHearing Aids .........................................$600 allowance/

3 calendar years/up to age 19Out of Area Benefit......................Coverage is provided

for urgent and emergent care when traveling outsideof the Preferred Care service area.

Eye Wear ...................................................20% discountHome Health Care, max 40 visits ..............$20 per visitAcupuncture, max 10 visits ................50% coinsurance

Plan Highlights for 2009Preferred Care is not just an insurance plan–we’re ahealth plan committed to helping you live well. We workclosely with our community’s physicians to make sureyou receive the quality, value and service you shouldexpect from a health plan. Below are just a few of themany reasons to choose Preferred Care in 2009:• Our Commercial plan is top ranked in New York

State–and in the entire U.S.–for quality of care andmember satisfaction, as ranked by U.S. News & WorldReport/NCQA America’s Best Health Plans 2007.

• Preferred Care is ranked #1 for customer satisfaction inits market by the New York State HMO Report Card.

• Each Preferred Care subscriber receives $50HealthDollars to spend on health, wellness and fitness programs!

Participating PhysiciansPreferred Care takes the quality of your medical careseriously. That’s why we make sure the more than 5,000physicians and other health care professionals in ournetwork have the proper training and licenses. Werespect their knowledge–therefore, they are key todeveloping our medical policies. And, should a serioushealth problem arise, Preferred Care will work closelywith you and your doctor to make sure you get the careyou need.

Affiliated HospitalsPreferred Care members are covered at area hospitals to which their participating physicians have admittingprivileges. Members may be directed to other hospitalsto meet special needs.

Pharmacies and PrescriptionsPreferred Care offers an incented formulary. PreferredCare members simply present their card at any pharmacyin our extensive network. At an out-of-network pharmacy,members pay their copayment plus the costs above thePreferred Care network rate.

Medicare CoverageMedicare-primary enrollees must enroll in the GoldPlan, Preferred Care’s Medicare Advantage Plan. Onceyou become eligible for Medicare, some of the GoldPlan’s copayments will differ from the copayments ofNYSHIP-primary enrollees. Please call for more details.

NYSHIP Code Number 058An IPA HMO serving individuals living or working in Genesee, Livingston, Monroe, Ontario,Orleans, Seneca, Steuben, Wayne, Wyoming andYates counties.

Preferred Care220 Alexander StreetRochester, NY 14607

For information:Preferred Care’s Member Services Department:585-325-3113 or 1-800-950-3224TTY: 585-325-2629Web site: www.preferredcare.org



Office Visits $15 per visit1

Specialty Office Visits $15 per visit1


Lab Tests No copaymentPathology No copaymentEKG/EEG $15 per visit1

Radiation $15 per visit1

Chemotherapy $15 per visit1

Women’s Health Care/OB GYNPap Tests No copaymentMammograms No copaymentPre and Postnatal Visits $15 per visit

(initial visit only)Bone Density Tests $15 per visit







Outpatient Mental Health2

max 20 visits per calendar year (combined individual and group)3 $15 per visit





ProstheticsInternal prosthetic appliances No copaymentExternal prosthetics 50% coinsuranceExternal breast prosthesis $15 copayment


Orthotics 50% coinsurancewhen deemed medically necessary by a participatingphysician. Vendor must obtain prior authorization.


Inpatient, 2 consecutive monthsper condition No copaymentOutpatient, max 30 visits combined $15 per visit1

Diabetic Supplies30-day supply Covered at the office visit copayment

Insulin and Oral Agents30-day supply Covered at the office visit copayment



Prescription DrugsRetail, 30-day supply $10 Tier I/

$25 Tier II/$40 Tier IIIMail Order, 90-day supply $30 Tier I/

$75 Tier II/$120 Tier IIIOne copayment for each 30-day supply, retail or mail order.Three copayments for 90-day supply through mail order.Coverage includes contraceptive drugs and devices,injectable and self-injectable medications, fertility drugs and enteral formulas.

Specialty DrugsSpecialty medications are covered only when purchasedat a participating network specialty pharmacy and aresubject to the same days supply and cost-sharingrequirements that apply to the retail pharmacy benefit.Mail order does not apply. A current list of specialtymedications and participating specialty pharmacies isavailable on our web site at www.univerahealthcare.com.Or, call Customer Service at the toll-free number locatedon the back of your ID card.1 No copayment for children age 18 and under when services

are received in a physician’s office or health center.2 Services can be provided in an outpatient facility or in a

provider’s office.3 Biologically based mental illness and coverage for children



Additional BenefitsDental4.......................................................25% discount

through Member Rewards ProgramVision5...................................$15 copayment for annual

routine eye exam from participating providers6

Hearing Aids ...............................................Not coveredOut of Area Benefit ..............................You are covered

for emergency services anywhere in the worldLenses and frames.....................................20% discount

from participating providers

4 Preventive only5 Routine only6 No copayment for children age 18 and under when services

are received in a physician’s office or health center.

Plan Highlights for 2009• No Copayment for Kids Age 18 and Under• AfterHours Program at Lifetime Health Medical

Group locations• 24 Hour Nurse Advice Line• Innovative On-Line Tools and Resources to help

you live well and live longer. Take a Health RiskAssessment, research health conditions and manageyour health care costs at: www.univerahealthcare.com.

Participating PhysiciansUnivera Healthcare includes 99 percent of WesternNew York’s doctors and more than 3,000 affiliatedproviders overall. Access Univera Healthcare’s web sitefor a complete listing of all participating providers, orcall Customer Service to request a provider directory.

Affiliated HospitalsUnivera Healthcare contracts with all Western NewYork hospitals. Access Univera Healthcare’s web site fora complete listing, or call Customer Service to request aprovider directory.

Pharmacies and PrescriptionsUnivera provides access to all major pharmacy chainsand most independent drug stores. Simply show thepharmacist your ID card. Members can also use our mail order services through Prime Mail® by calling 1-866-260-0487. Univera offers an incented formulary.

Medicare CoverageMedicare-primary retirees are required to enroll inSeniorChoice, the Univera Medicare Advantage Plan.To qualify you must be enrolled in Medicare Parts A and B and live in one of the counties listed below.Copayments may differ from the copayments of aNYSHIP-primary enrollee.

NYSHIP Code Number 057A Network HMO serving individuals living orworking in Cattaraugus, Erie, Genesee, Niagara,Orleans and Wyoming counties.

Univera Healthcare205 Park Club LaneBuffalo, NY 14221-5239

For information:1-800-337-3338TTY: 1-800-421-1220Web site: www.univerahealthcare.com


NYSHIP Online has been redesigned to provide you with more targeted information about your NYSHIP benefits.Visit the New York State Department of Civil Service web site at www.cs.state.ny.us and click on Benefit Programs,then NYSHIP Online. Select your group if prompted. If the group at the top of the NYSHIP Online home page isnot your employee group, be sure to choose Change Your Group.

If you do not have access to the internet, your local library may offer computers for your use.

Ask your agency HBA for a copy of the NYSHIP Online flyer that provides helpful navigation information.

NYSHIP Online

Reminder: If you are an active employee of New York State and a registered user of MyNYSHIP, you may change your option online during the Option Transfer Period. See your agency HBA if you have questions.


How to find answers to your benefit questions and gain access to additional important information:

• If you are an active State employee, contact your agency Health Benefits Administrator (HBA), usually located in your agency’s Personnel Office.

• If you have questions regarding health insurance claims for The Empire Plan, call 1-877-7-NYSHIP (1-877-769-7447) toll free and choose the appropriate program on the main menu. HMO enrollees should contact their HMO directly.

• A comprehensive list of contact information for HBAs, HMOs, government agencies, Medicare and other important resources is available on NYSHIP Online in the Using Your Benefits section.

Telephone Numbers

Health Benefits Administrators

The New York State Department of Civil Service, which administers NYSHIP, produced this booklet incooperation with The Empire Plan carriers and Joint Labor/Management Committees on Health Benefits.

Care has been taken to ensure the accuracy of the material contained in this booklet. However, the HMOcontracts and the certificate of insurance from The Empire Plan carriers with amendments are thecontrolling documents for benefits available under NYSHIP.

New York StateDepartment of Civil ServiceAlfred E. Smith State Office BuildingAlbany, NY 12239www.cs.state.ny.us

Choices was printed using recycled paper and environmentally sensitive inks. AL0846 Choices 09/Actives Settled

It is the policy of the State of New York Department of Civil Service to provide reasonable accommodation to ensure effective communication of information in benefits publications to individuals with disabilities. These publications are also available on the Department of Civil Serviceweb site (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,please contact your agency Health Benefits Administrator. COBRA Enrollees: Contact the Employee Benefits Division.

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