JAN UARY 2010New York State Health Insurance Program (NYSHIP)For Active Employees, Retirees, Vestees, Dependent Survivorsand their Dependents enrolled through Participating Agencies with Empire Plan Benefits and Young Adult Option EnrolleesRead and Savethis Report for importantinformation about benefitchanges.In This Report12Young Adult Option CoverageNYS Continuation ofCoverage; Annual Deductible;Hearing Aid Benefits;Immunization Coverage3Future Moms Program;Specialty Pharmacy Program;4-5 Half Tablet Program;RemindersSpecial SectionNYSHIP General InformationBook and Empire PlanCertificate Amendments6Annual NoticeCopaymentsSee pages 253 and 254 ofyour Empire Plan CertificateAmendments for a completelist of your 2010 copayments.NYSHIP ChangesYoung Adult Option CoverageAs the result of a change in NYS InsuranceLaw, effective January 1, 2010, unmarriedyoung adults through age 29 are eligible forNYSHIP health insurance coverage underthe“Young Adult Option.”The Young Adult Option does not changeNYSHIP’s maximum age criteria fordependent coverage available toenrollees, but allows the adult child of anenrollee who meets the establishedcriteria to purchase individual healthinsurance coverage through NYSHIPwhen the young adult does nototherwise qualify as a NYSHIPdependent. Either the young adult orhis/her parent may enroll the young adultin the Young Adult Option, and eithermay elect to be billed for the NYSHIPpremium. The cost of the Young AdultOption is the full share Individualpremium. Refer to the Amendment onpage 219 for eligibility criteria and otheradditional details.A young adult is entitled to the samehealth insurance coverage as his/herparent provided the young adult lives,works or resides in New York State or theinsurer’s service area.There is an initial open enrollment periodfor the Young Adult Option throughout2010. Beginning in 2011 there will be a30-day annual open enrollment period.Additionally, a young adult may enrollwhen NYSHIP eligibility is lost due to ageor when a young adult is newly eligiblebecause of a change in circumstances,such as loss of employer-sponsoredhealth benefits.The Young Adult Option application, ratesand FAQs are available on the Department’sweb site ndex.cfm. Orcontact the parent’s Health BenefitsAdministrator at his/her ParticipatingAgency for information and to enroll.Changes to NYSHIP eligibility foradult children resulting from therecently enacted Federal HealthCare Reform will take effectJanuary 1, 2011. Details regardingeligibility criteria and the cost ofthis coverage are subject toFederal regulations, which havenot yet been issued. Informationwill be mailed to enrollees andposted to our web site when itbecomes available.
New York State: SupplementalContinuation of CoverageEffective January 1, 2010, The EmpirePlan adopted New York State legislationto allow enrollees who have exhaustedtheir federal Consolidated OmnibusBudget Reconciliation Act (COBRA)coverage to extend NYSHIP coverage foran additional 18 months under the state’scontinuation of coverage law.Under the new legislation, if you loseCOBRA coverage because you havereached the end of your 18 or 29 monthcontinuation period, you may requestadditional coverage under the New YorkState Insurance Law that will extendcoverage until the earlier of: 36 months (combined length ofCOBRA and New York State coverage); The end of the period in whichpremiums were last paid; The date the enrollee becomesentitled to Medicare benefits; or The date New York State no longerprovides group health care coverageto any of its enrollees.Enrollees will have 60 days from the laterof the end of their COBRA continuationperiod or receipt of notice of eligibility toapply in writing for the New York StateContinuation of Coverage. The cost ofcoverage continuation will be the fullpremium cost for individual coverageplus a two percent administrative fee.Benefit Changes2010 Annual Deductible andCoinsurance Maximum forBasic Medical and Non-NetworkMental Health and Substance AbusePractitioner ServicesAnnual Deductible: 375Coinsurance Maximum: 1,033For calendar year 2010, The Empire Planannual deductible for services performedand supplies prescribed by nonparticipating or non-network providersis 375 for you, 375 for your enrolledspouse/domestic partner and 375 for allcovered dependent children combined.You must meet the deductible beforebenefits are paid for your claims.The annual deductible for the BasicMedical Program and the non-networkportion of the Mental Health andSubstance Abuse Program cannot becombined with each otheror with the Managed Physical MedicineProgram annual deductible for nonnetwork services.Effective January 1, 2010, the coinsurancemaximum (out-of-pocket expense) is 1,033 for you, 1,033 for your enrolledspouse/domestic partner and 1,033 forall covered dependent children combined.After each coinsurance maximum isreached, you will be reimbursed 100percent of the reasonable and customaryamount, or 100 percent of the billedamount, whichever is less, for coveredservices. You will still be responsible forany charges above the reasonable andcustomary amount and for any penaltiesunder the benefits management programs.Enhanced Hearing Aid Benefitsthrough EPIC Hearing Service PlanThe Empire Plan has enhanced its hearingaid benefit for enrollees and eligibledependents with the addition of theHearing Service Plan (HSP), provided byEPIC Hearing Healthcare. The EPIC HSPis a voluntary program that offersnationwide access to hearing aids andservices. The Program’s review processassures you are receiving all appropriatetests and services as well as the most2EPR-PA-10-1appropriate technology for the bestprice. Although your hearing aid benefitmaximum remains unchanged, theEPIC HSP offers you and your eligibledependents an additional option inutilizing your hearing aid benefit. TheEPIC HSP coordinates access to qualityhearing care professionals throughoutthe State of New York and the nation andallows for direct billing to the Plan, up tothe maximum benefit, so enrollees donot have to pay any upfront costs forhearing aids. Any amount over themaximum benefit is your responsibility.The EPIC HSP provides the following: Hearing aid professionals available inall 50 states Access to all major hearing aidmanufacturers Prices are never marked up fromwholesale Hearing aid price lists are providedto enrollees and dependents uponrequest All hearing aids carry an extended threeyear warranty, include the first year’ssupply of batteries and have a 45-day,no risk trial period in New York StateIf you would like to learn more about theEPIC HSP, or if you need assistance inlocating an HSP provider, please call tollfree 866-956-5400.Immunization CoverageImmunizations have become a topicof interest this year because of theNovel H1N1 (swine flu) virus. As a result,it is very important that Empire Planenrollees understand their coveragefor immunizations.There is no copayment under theParticipating Provider Program for routinewell-child care for children up to age 19including pediatric examinations,immunizations and the cost of oral andinjectable substances when administeredaccording to pediatric care guidelines. TheH1N1 vaccine is included in the vaccinesoffered to children under pediatric careguidelines. Coverage is also availableunder the Basic Medical Program subjectto deductible and coinsurance.
Adult immunizations are covered whenprovided by a participating provider.You pay only a copayment for influenza(including the H1N1 vaccine), pneumonia,measles-mumps-rubella (MMR), varicella(chickenpox) and tetanus immunizations.Female enrollees and dependents age 19through 26 years pay a copayment forhuman papiloma virus (HPV) immunizationfor cervical cancer prevention, and EmpirePlan enrollees and dependents age 55 orolder are covered for the Shingles (HerpesZoster) vaccine. If an immunization is notidentified as covered it will not beconsidered for reimbursement. Adultimmunizations are not covered under theBasic Medical Program.The Empire PlanFuture Moms ProgramIMPORTANT! Vaccines dispensed oradministered by the pharmacy are notcovered by The Empire Plan.If you are interested in the Future Moms Program, call The Empire Plan tollfree at 1-877-7-NYSHIP (1-877-769-7447) and choose Empire BlueCrossBlueShield to enroll in the program.This voluntary program is offered to Empire Plan enrollees at no additionalcost and provides support and information designed to help you have asmooth pregnancy, a safe delivery and a healthy child. If you’re pregnant, orhope to be in the near future, you know there’s nothing more importantthan safeguarding your health and the health of your baby.When you enroll in Future Moms, you’ll be contacted by a Nurse Coach, aregistered nurse, who will walk you through a health assessment over thephone. If you’re not currently experiencing any health concerns, your NurseCoach will simply arrange to check back with you periodically. But, if youneed assistance in dealing with health issues, your Nurse Coach willschedule more frequent calls to check on your progress. Your Nurse Coachcan also arrange for a free phone consultation with a specialist to answeryour questions. Registered nurses are available 24 hours a day 7 days a weekto answer your questions.Specialty Pharmacy ProgramEffective April 1, 2010, The Empire Plan willadd a Specialty Pharmacy Program to yourPrescription Drug coverage. The SpecialtyPharmacy Program will offer enhancedservices to individuals using specialtydrugs and change how you obtain thosedrugs under the Prescription DrugProgram. Most specialty drugs will only becovered when dispensed by The EmpirePlan’s designated specialty pharmacy,Accredo, a subsidiary of Medco.Accredo was selected to administerthis Program because of its provenexperience with providing servicesthat help promote superior clinicaloutcomes. Accredo will ensure thatspecialty medications are utilized basedon U.S. Food & Drug Administration (FDA)and best practice guidelines.Specialty drugs are used to treat complexconditions and usually require specialhandling, special administration, orintensive patient monitoring. The majordrug categories covered under theProgram include, but are not limited to,drugs for Rheumatoid Arthritis, Cancer,Multiple Sclerosis, Human GrowthHormones, Deep Vein Thrombosis andAnemia (medications used to treatdiabetes are not considered specialtymedications). When Accredo dispenses aspecialty medication, the applicable mailservice copayment will be charged.The Program will provide enrollees withenhanced services that include diseaseand drug education, compliancemanagement, side-effect management,safety management, expedited,scheduled delivery of your medicationsat no additional charge, refill remindercalls and all necessary supplies suchas needles and syringes applicable tothe medication.Enrollees currently taking drugs includedin this Program will receive a letter, priorto April 1, 2010, describing the Programin more detail. When enrollees begintherapy on one of the drugs includedin the Program, a letter will be sentdescribing the program and any actionnecessary to participate in it.The complete list of specialty drugsincluded in the Specialty PharmacyProgram will be available April 1, 2010 onthe Department of Civil Service websiteat https://www.cs.state.ny.us. Each ofthese drugs can be ordered through theSpecialty Pharmacy Program using theMedco mail order form sent to thefollowing address:Medco by MailP.O. Box 6500Cincinnati, OH 45201-6500To request mail service envelopes,refills or to speak to a specialty-trainedpharmacist or nurse regarding theSpecialty Pharmacy Program, call TheEmpire Plan toll free at 1-877-7-NYSHIP(1-877-769-7447), choose The EmpirePlan Prescription Drug Program, and askto speak with Accredo, 24 hours a day,seven days a week.Continued on page 4EPR-PA-10-13
Continued from page 3The Empire Plan Half Tablet ProgramSome recent articles have questionedthe safety and efficacy of pill splittingprograms. In most, the conclusion is thatpill splitting programs are safe and savethe patient money if the medicationsare clinically determined to be safe forsplitting. The Empire Plan Half TabletProgram offered by The Empire Planand administered by UnitedHealthcareprovides many safeguards to mitigateagainst any possible safety questions.The Empire Plan requires the followingclinical criteria for medications to qualifyfor the Half Tablet Program: Each drug accepted for the Half TabletProgram must be approved byUnitedHealthcare’s National Pharmacyand Therapeutic Committee. Medications must have a wide marginof safety so that minimal differences intablet sizes, after splitting, will notdisturb the efficacy of the medicine. Tablets must be able to be splitrelatively evenly without crumbling. Medications must remain chemicallystable after splitting. Capsules, liquids, topical medicationsand certain coated tablets do not qualify.You should only participate in theprogram if your doctor determines thatpill splitting is appropriate for you.For an updated list of the medicationseligible for the Half Tablet Program goto https://www.cs.state.ny.us and selectBenefit Programs in the left handnavigation on the home page. Followthe prompts to NYSHIP Online thenchoose Find a Provider. Scroll to theMedco links and click on Empire PlanHalf Tablet Program. If you have otherquestions, call The Empire Plan toll freeat 1-877-7-NYSHIP (1-877-769-7447)and choose The Empire Plan PrescriptionDrug Program.4EPR-PA-10-1RemindersDependent VerificationEnrollees with family coverage arerequired to submit documentation ofeligibility for each of their dependentscovered under NYSHIP to Budco HealthService Solutions, the vendor contractedto perform the Dependent EligibilityVerification Project, no later than January15, 2010. If you do not respond to theirrequest for documentation, or do notsubmit adequate documentation, orbecause you submitted incompletedocumentation, your dependent wasremoved from coverage retroactively toFebruary 1, 2009. The date for removalfrom coverage was February 24, 2010.To reinstate coverage for any eligibledependents removed from coverage, youmust provide proof of eligibility directlyto the Department of Civil Service.If you have questions, please visit theDepartment of Civil Service web site atwww.cs.state.ny.us/nyshipeligibilityprojector call 1-888-358-2192 Monday throughFriday 9:00 a.m. to 7:30 p.m. Eastern Time.The toll free telephone number will beavailable through June 30, 2010.The Empire Plan At A Glanceand Copayment CardsIn late November 2009, the January 1, 2010Empire Plan At A Glance along with January1, 2010 Copayment Cards and the 2010Flexible Formulary List were mailed to yourhome. These are important pieces tounderstand your 2010 benefits; be sure toread them and keep them handy. If youneed additional copayment cards, contactyour agency Health Benefits Administrator.Reimbursement of the MedicarePart B Income-Related MonthlyAdjustment Amount (IRMAA)for Medicare-Primary EnrolleesMedicare Law requires some people topay a higher premium for their MedicarePart B coverage based on their income.If you and/or any of your enrolleddependents are Medicare-primary andreceived a letter from the Social SecurityAdministration (SSA) requiring thepayment of an Income-Related MonthlyAdjustment Amount (IRMAA) in additionto the standard Medicare Part B premiumfor 2009, you are eligible to bereimbursed for this additional premiumby your Agency. Note: If your 2007adjusted gross income was less thanor equal to 85,000 ( 170,000 if youfiled taxes as married filing jointly)you are NOT eligible for any additionalreimbursement this year.To claim the additional IRMAAreimbursement, eligible enrollees arerequired to apply for and document theamount paid in excess of the standardpremium. Contact your Agency HealthBenefits Administrator for information onhow to apply, a list of the documentsrequired or questions on IRMAA.Continued on page 5
Continued from page 4The 2010 CensusThe census is a count of everyone living inthe United States. This includes people ofall ages, races, ethnic groups, both citizensand non-citizens. Census questionnaireswill be mailed in March 2010.It’s Easy - The questionnaire containsonly a few simple questions and takesjust a few minutes to answer and return,postage free, by mail.Safe - The Census Bureau protectsinformation that identifies respondentsand their households for 72 years.And Important - It determines theannual distribution of 300 billion ofgovernment funding for criticalcommunity services and generatesthousands of jobs across the country.Participation ensures New Yorkers gettheir fair share of government funding,census jobs and Congressional seats.Annual Notice of Mastectomy and Reconstructive Surgery BenefitsThe Empire Plan covers inpatient hospital care for lymph node dissection,lumpectomy and mastectomy for treatment of breast cancer for as longas the physician and patient determine hospitalization is medicallynecessary. The Plan covers all stages of reconstructive breast surgeryfollowing mastectomy, including surgery of the other breast to produce asymmetrical appearance. The Plan also covers treatment for complicationsof mastectomy, including lymphedema. Prostheses and mastectomy brasare covered.Call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and selectUnitedHealthcare if you have questions about your coverage for implants,breast forms or other prostheses related to breast cancer treatment.Empire Plan Benefits Management Program requirements apply. See yourEmpire Plan Certificate and Empire Plan Reports.The Empire Plan Report is published by theEmployee Benefits Division of the State ofNew York Department of Civil Service. TheEmployee Benefits Division administers theNew York State Health Insurance Program(NYSHIP). NYSHIP provides your healthinsurance benefits through The Empire Plan.State of New YorkDepartment of Civil ServiceEmployee Benefits DivisionAlbany, New York 12239518-457-5754 (Albany area)1-800-833-4344(U.S., Canada, Puerto Rico, Virgin Islands)www.cs.state.ny.usEPR-PA-10-15
State of New YorkDepartment of Civil ServiceEmployee Benefits DivisionP.O. Box 1068Schenectady, New York 12301-1068www.cs.state.ny.usCHANGE SERVICE REQUESTEDSAVE THIS DOCUMENTInformation for the Enrollee, Enrolled Spouse/Domestic Partnerand Other Enrolled DependentsPA Empire Plan Report – January 2010!Please do not send mail orcorrespondence to the returnaddress. See page 5 foraddress information.It is the policy of the State of New York Department of Civil Service to provide reasonable accommodation to ensure effective communication of information inbenefits publications to individuals with disabilities. These publications are also available on the Department of Civil Service web site (www.cs.state.ny.us). Clickon Benefit Programs, then NYSHIP Online for timely information that meets universal accessibility standards adopted by New York State for NYS agency websites. If you need an auxiliary aid or service to make benefits information available to you, please contact your agency Health Benefits Administrator. New YorkState and Participating Employer Retirees and COBRA Enrollees: Contact the Employee Benefits Division at 518-457-5754 (Albany area) or 1-800-833-4344 (U.S.,Canada, Puerto Rico, Virgin Islands).This Report was printed using recycled paper and environmentally sensitive inks.6EPR-PA-10-1PA0175EPR-PA-Empire Plan-10-1