paep aag jan 2019

Transcript

1 AT A GLANCE | Participating Agencies PA January 1, 2019 For Active Employees, Retirees, Vestees and Dependent Survivors enrolled in The Empire Plan through Participating Agencies, their This guide briefly describes enrolled Dependents and for COBRA Enrollees and Young Adult Empire Plan benefits. It is not Option Enrollees with Empire Plan benefits a complete description and is subject to change. For a complete description of your benefits and responsibilities, refer to Empire Plan Certificate your Certificate Amendments. and For information regarding your New York State Health Insurance Program (NYSHIP) eligibility or enrollment, contact your Health Benefits Administrator. If you have questions regarding specific benefits or claims, contact the appropriate Empire Plan administrator (see page 23). New York State Department of Civil Service, Employee Benefits Division, Albany, NY 12239 www.cs.ny.gov/employee-benefits

2 WHAT’S NEW • In-network Out-of-Pocket Limit – For 2019, the maximum out-of-pocket limit for covered, in-network services under The Empire Plan is $7,900 for Individual coverage and $15,800 for Family coverage, split between the Hospital, Medical/Surgical, Mental Health and Substance Abuse and Prescription Drug Programs. See page 3 for more information. • Combined Annual Deductible for the Basic Medical Program and non-network coverage under the Home Care Advocacy Program and Mental Health and Substance Abuse Program increases from $1,000 to $1,250. See page 3 for more information. • Combined Annual Coinsurance Maximum for the Basic Medical Program and non-network coverage under the Hospital Program and Mental Health and Substance Abuse Program increases from $3,000 to $3,750. See page 3 for more information. • 2019 Copayment Changes – Beginning January 1, 2019, new copayments are in effect for the Hospital, Medical/Surgical and Mental Health and Substance Abuse Programs. See page 24 for an overview of the new copayments. • 2019 Empire Plan Flexible Formulary Drug List – The annual update lists the most commonly prescribed generic and brand-name drugs included in the 2019 Empire Plan Flexible Formulary and newly excluded drugs with 2019 Empire Plan Flexible Formulary alternatives. • Elimination of New to You Prescription Drug Requirement – Effective January 1, 2019, the 30-day quantity limit for maintenance medications required by the New to You Program has been eliminated. See page 18 for details. • New Number for Diabetic Supplies Pharmacy – The Empire Plan Diabetic Supplies Pharmacy has a new toll-free number. The vendor for the pharmacy is still Edgepark Medical Supplies, but you must now contact them at 1-800-321-0591 to place an order. • Skilled Nursing Facility Care – Effective January 1, 2019, the maximum number of benefit days of care received in a skilled nursing facility will be 120 days of care for each spell of illness. Each day of care in a skilled nursing facility will continue to count as one-half benefit day of care. Applies to Plan-primary enrollees and dependents only.

3 Quick Reference The Empire Plan is a comprehensive health insurance program for New York’s public employees and their families. The Plan has four main parts: Hospital Program administered by Empire BlueCross BlueShield Provides coverage for inpatient and outpatient services provided by a hospital or skilled nursing facility and hospice care. Includes the Center of Excellence for Transplants Program. Also provides inpatient Benefits Management Program services, including preadmission certification of hospital admissions and admission or transfer to a skilled nursing facility, concurrent reviews, discharge planning, inpatient medical case management and the Empire Plan Future Moms Program. Medical/Surgical Program administered by UnitedHealthcare Provides coverage for medical services, such as office visits, convenience care clinics, surgery and diagnostic testing under the Participating Provider, Basic Medical and Basic Medical Provider Discount Programs. Coverage for physical therapy, chiropractic care and occupational therapy is provided through the Managed Physical Medicine Program. Also provides coverage for home care services, durable medical equipment and certain medical supplies through the Home Care Advocacy Program; the Prosthetics/Orthotics Network; Center of Excellence Programs for Cancer and for Infertility; and Benefits Management Program services, including Prospective Procedure Review for MRIs, MRAs, CT scans, PET scans, nuclear medicine tests, voluntary specialist consultant evaluation services and outpatient medical case management. Mental Health & Substance Abuse Program administered by Beacon Health Options, Inc. Provides coverage for inpatient and outpatient mental health care and substance use care services. Also provides preadmission certification of inpatient and certain outpatient services, concurrent reviews, case management and discharge planning. Prescription Drug Program administered by CVS Caremark Provides coverage for prescription drugs dispensed through Empire Plan network pharmacies, the mail service pharmacy, the specialty pharmacy and non-network pharmacies. See Contact Information on page 23.

4 Benefits Management Program The Empire Plan Benefits Management Program helps to protect the enrollee and allows the Plan to continue to cover essential treatment for patients by coordinating care and avoiding unnecessary services. The Benefits Management Program precertifies inpatient medical admissions and certain procedures, assists with discharge planning and provides inpatient and outpatient medical case management. In order to receive maximum benefits under the Plan, following the Benefits Management Program requirements – including obtaining precertification for certain services – is required when The Empire Plan is your primary coverage (pays first, before another health plan or Medicare). YOU MUST CALL for preadmission certification If The Empire Plan is primary for you or your covered dependents, you must call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Hospital Program (administered by Empire BlueCross BlueShield): • Before a scheduled (nonemergency) hospital admission, skilled nursing facility admission/transfer or transplant surgery.† • Before a maternity hospital admission.† Call as soon as a pregnancy is certain. • Within 48 hours, or as soon as reasonably possible, after an emergency or urgent hospital admission.† If you do not call and the Hospital Program does not certify the hospitalization, you will be responsible for the entire cost of care determined not to be medically necessary. † These services are subject to a $200 penalty if the hospitalization is determined to be medically necessary, but not precertified. Other Benefits Management Program services provided by the Hospital Program include: • Concurrent review of hospital inpatient treatment • Discharge planning for medically necessary services post-hospitalization • Inpatient medical case management for coordination of covered services for certain catastrophic and complex cases that may require extended care • The Empire Plan Future Moms Program for early risk identification YOU MUST CALL for Prospective Procedure Review If The Empire Plan is primary for you or your covered dependents, you must call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Medical/Surgical Program (administered by UnitedHealthcare) before receiving the following scheduled (nonemergency) diagnostic tests: • Magnetic resonance imaging (MRI) • Magnetic resonance angiography (MRA) • Computerized tomography (CT) scan • Positron emission tomography (PET) scan • Nuclear medicine test Precertification is required unless you are having the test as an inpatient in a hospital. If you do not call, you will pay a larger part of the cost. If the test or procedure is determined not to be medically necessary, you will be responsible for the entire cost. Other Benefits Management Program services provided by the Medical/Surgical Program include: • Coordination of voluntary specialist consultant evaluation • Outpatient medical case management for coordination of covered services for certain catastrophic and complex cases that may require extended care Be sure to review the Benefits Management Program section of your Empire Plan Certificate and subsequent for complete information on the program’s services and requirements. Certificate Amendments AAG-PA-1/19 2

5 Out-Of-Pocket Costs In-network Out-of-Pocket Limit As a result of the federal Patient Protection and Affordable Care Act provisions, there is a limit on the amount you will pay out of pocket for in-network services/supplies received during the plan year. Out-of-Pocket Limit: The amount you pay for network services/supplies is capped at the out-of-pocket limit. Network expenses include copayments you make to providers, facilities and pharmacies (network expenses do not include premiums, deductibles or coinsurance). Once the out-of-pocket limit is reached, network benefits are paid in full. Beginning January 1, 2019, the out-of-pocket limits for in-network expenses are as follows: Individual Coverage Family Coverage • $5,150 for in-network expenses incurred under • $10,300 for in-network expenses incurred under the Hospital, Medical/Surgical and Mental Health the Hospital, Medical/Surgical and Mental Health and Substance Abuse Programs and Substance Abuse Programs • $2,750 for in-network expenses incurred under • $5,500 for in-network expenses incurred under the Prescription Drug Program* the Prescription Drug Program* * Does not apply to Medicare-primary enrollees or Medicare-primary dependents. Refer to your Empire Plan Medicare Rx documents for information about your out-of-pocket expenses. Out-of-Network Combined Annual Deductible The combined annual deductible is $1,250 for the enrollee, $1,250 for the enrolled spouse/domestic partner and $1,250 for all dependent children combined. The combined annual deductible must be met before Basic Medical Program expenses, non-network expenses under the Home Care Advocacy Program and outpatient, non-network expenses under the Mental Health and Substance Abuse Program will be considered for reimbursement. Combined Annual Coinsurance Maximum The combined annual coinsurance maximum is $3,750 for the enrollee, $3,750 for the enrolled spouse/ domestic partner and $3,750 for all dependent children combined. Coinsurance amounts incurred for non-network Hospital Program coverage, Basic Medical Program coverage and non-network Mental Health and Substance Abuse Program coverage count toward the combined annual coinsurance maximum. Copayments to Medical/Surgical Program participating providers and to Mental Health and Substance Abuse Program network practitioners also count toward the combined annual coinsurance Note: Copayments made to network facilities do not count toward the combined annual maximum. ( coinsurance maximum.) Preventive Care Services Your Empire Plan benefits include provisions for expanded coverage of preventive health care services required by the federal Patient Protection and Affordable Care Act (PPACA). When you meet established criteria (such as age, gender and risk factors) for certain preventive care services, those preventive services are provided to you at no cost when you use an Empire Plan participating provider or for examples of covered services. 2019 Empire Plan Preventive Care Coverage Chart network facility. See the For further information on PPACA preventive care services and criteria to receive preventive care services at no cost, visit www.hhs.gov/healthcare/rights/preventive-care. AAG-PA-1/19 3

6 Center Of Excellence Programs For further information on any of the programs listed below, refer to your and the Empire Plan Certificate Reporting On Center of Excellence Programs. In some cases, a travel, lodging and meal allowance publication may be available. If you do not use a Center of Excellence, benefits are provided in accordance with Hospital and/or Medical/Surgical Program coverage. Cancer Services* YOU MUST CALL The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Medical/Surgical Program or call the Cancer Resource Services toll free at 1-866-936-6002 and register to participate Paid-in-full benefits are available for cancer services at a designated Center of Excellence. You will also receive nurse consultations, assistance locating cancer centers and a travel allowance, when applicable. Transplants Program YOU MUST CALL The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Hospital Program for prior authorization Paid-in-full benefits are available for the following transplant services when authorized by the Hospital Program and received at a designated Center of Excellence: pretransplant evaluation of transplant recipient; inpatient and outpatient hospital and physician services; and up to 12 months of follow-up care. You must call The Empire Plan for preauthorization of the following transplants provided through the Center of Excellence for Transplants Program: bone marrow, cord blood stem cell, heart, heart-lung, kidney, liver, lung, pancreas, pancreas after kidney, peripheral stem cell and simultaneous kidney/pancreas. When applicable, a travel allowance is available. If you choose to have your transplant in a facility other than a designated Center of Excellence (or if you require a small bowel or multivisceral transplant) you may still take advantage of the Hospital Program case management services, in which a nurse will help you through the transplant process, if you enroll in the Center of Excellence for Transplants Program. If a transplant is authorized but you do not use a designated Center of Excellence, benefits will be provided in accordance with Hospital and/or Medical/Surgical Program coverage. Transplant surgery preauthorization is required whether or not you choose to participate in the Center Note: of Excellence for Transplants Program. To enroll in the Program and receive these benefits, The Empire Plan must be your primary coverage. Infertility Benefits* YOU MUST CALL The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Medical/Surgical Program for prior authorization Paid-in-full benefits are available, subject to the lifetime maximum for Qualified Procedures ($50,000 per covered person) including any applicable travel allowance, when you choose a Center of Excellence for Infertility and receive prior authorization. To request a list of Qualified Procedures, or for preauthorization of infertility benefits, call the Medical/Surgical Program. Center of Excellence Program Travel Allowance When you are enrolled in the Center of Excellence Program or use a Center of Excellence for preauthorized infertility services, a travel, lodging and meal expenses benefit is available for travel within the United States. The benefit is available to the patient and one travel companion when the facility is more than 100 miles (200 miles for airfare) from the patient’s home. If the patient is a minor child, the benefit will include coverage for up to two companions. Benefits will also be provided for one lodging per day. Reimbursement for lodging and meals will be limited to the U.S. General Services Administration per diem rate. Reimbursement for automobile mileage * Program requirements apply even if Medicare or another health plan is primary to The Empire Plan. AAG-PA-1/19 4

7 will be based on the Internal Revenue Service medical rate. Only the following travel expenses are reimbursable: lodging, meals, auto mileage (personal and rental car), economy class airfare and coach train fare. Once you arrive at your lodging and need transportation from your lodging to the Center of Excellence, certain costs of local travel are also reimbursable, including local subway, basic ridesharing, taxi or bus fare; shuttle; parking; and tolls. Hospital Program Call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) PRESS 2 OR SAY and press or say 2 to reach the Hospital Program The Hospital Program provides benefits for services provided in a network or non-network inpatient or outpatient hospital, skilled nursing facility or hospice setting. Services and supplies must be covered or as amended and medically necessary, as defined in the current version of your Empire Plan Certificate . The Medical/Surgical Program provides benefits for certain medical Certificate Amendments in subsequent and surgical care when it is not covered by the Hospital Program. Call the Hospital Program for preadmission certification or if you have questions about your benefits, coverage or an Explanation of Benefits statement. Network coverage applies when you receive emergency or urgent services in a non-network hospital, or when you use a non-network hospital because you do not have access to a network hospital. Call the Hospital Program to determine if you qualify for network coverage at a non-network hospital based on access. Network Coverage You pay only applicable copayments for services/supplies provided by a hospital, skilled nursing facility or hospice that is part of The Empire Plan network. No deductible or coinsurance applies. Network coverage also applies when The Empire Plan provides coverage that is secondary to other coverage. Non-network Coverage When you use a facility that is not part of The Empire Plan network and do not qualify for network coverage (see above), your out-of-pocket costs are higher. • You are responsible for a coinsurance amount of 10 percent of billed charges for inpatient facility services until you meet the combined annual coinsurance maximum. • You are responsible for a coinsurance amount of 10 percent of billed charges or a $75 copayment, whichever is greater, for outpatient services until you meet the combined annual coinsurance maximum. Hospital Inpatient YOU MUST CALL for preadmission certification (see page 2) The Hospital Program covers you for a combined maximum of up to 365 days per spell of illness for inpatient diagnostic and therapeutic services or surgical care provided by a network and/or non-network hospital. Inpatient hospital coverage is provided under the Medical/Surgical Program’s Basic Medical Program after Hospital Program benefits end. Network Coverage Non-network Coverage Inpatient stays in a non-network hospital are subject Inpatient stays in a network hospital are paid in full. to a coinsurance amount of 10 percent of billed charges, until you meet the combined annual coinsurance maximum (see page 3). Network coverage is provided once the combined annual coinsurance maximum is satisfied. AAG-PA-1/19 5

8 Hospital Outpatient Emergency Department Non-network Coverage Network Coverage Network coverage applies to emergency services You pay one $100 copayment per visit to an received in a non-network hospital. emergency department, including use of the facility for emergency care, services of the attending physician, services of providers who administer or interpret laboratory tests and electrocardiogram services. Other physician charges are covered under the Medical/ Surgical Program (see page 7). The copayment is waived if you are admitted as an inpatient directly from the emergency department. Outpatient Department or Hospital Extension Clinic The hospital outpatient services covered under the Program are the same whether received in a network or non-network hospital outpatient department or in a network or non-network hospital extension clinic. The following benefits apply to services received in the outpatient department of a hospital or a hospital extension clinic. Non-network Coverage Network Coverage You are responsible for a coinsurance amount of Outpatient surgery is subject to a $95 copayment. 10 percent of billed charges or a $75 copayment You pay one $50 copayment per visit for diagnostic (whichever is greater) per visit, until you meet the radiology and diagnostic laboratory tests. combined annual coinsurance maximum (see page 3). You have paid-in-full benefits for: Network coverage is provided once the combined • Preadmission and/or presurgical testing prior to annual coinsurance maximum is satisfied. an inpatient admission • Chemotherapy • Radiation therapy • Anesthesiology • Pathology • Dialysis The following services are paid in full when designated preventive according to the Patient Protection and Affordable Care Act: • Bone mineral density tests • Colonoscopies • Mammograms* • Pap smears • Proctosigmoidoscopy screenings • Sigmoidoscopy screenings * Screening, diagnostic and 3-D mammograms are paid in full under New York State law. Physical therapy following a related hospitalization or related inpatient or outpatient surgery is subject to a $25 copayment per visit. Physical therapy must start within six months from your discharge from the hospital or the date of your outpatient surgery and be completed within 365 days from the date of hospital discharge or outpatient surgery. Medically necessary physical therapy is covered under the Managed Physical Medicine Program when not covered under the Hospital Program (see page 12). AAG-PA-1/19 6

9 Skilled Nursing Facility Care YOU MUST CALL for preadmission certification (see page 2) Benefits are subject to the requirements of the Empire Plan Benefits Management Program if The Empire Plan provides your primary health coverage. The Empire Plan does not provide Skilled Nursing Facility benefits, even for short-term rehabilitative care, for Retirees, Vestees, and Dependent Survivors or their dependents who are eligible for primary benefits from Medicare. Network Coverage Non-network Coverage Skilled nursing facility care is paid in full when Skilled nursing facility care is covered when provided provided in place of hospitalization. Limitations in place of hospitalization. You will be responsible for Empire Plan Certificate apply; refer to your a coinsurance amount of 10 percent of billed charges, regarding conditions of coverage. up to the combined annual coinsurance maximum. Network coverage is provided once the combined annual coinsurance maximum is satisfied (see page 3). Hospice Care Network Coverage Non-network Coverage Care provided by a licensed hospice program is paid You will be responsible for a coinsurance amount Empire Plan Certificate regarding in full. Refer to your of 10 percent of billed charges, up to the combined conditions of coverage. annual coinsurance maximum, for care provided by a licensed hospice program. Network coverage is provided once the combined annual coinsurance maximum is satisfied (see page 3). Medical/Surgical Program Benefits for Physician/Provider Services Received in a Hospital Inpatient or Outpatient Setting When you receive covered services from a physician or other provider in a hospital, and those services are billed by the provider (not the facility), the following Medical/Surgical Program benefits apply: Participating Provider Program Covered services are paid in full when the provider participates in The Empire Plan network. Basic Medical Program If you receive covered radiology, anesthesiology or pathology services in connection with covered inpatient or outpatient services at an Empire Plan network hospital and The Empire Plan provides your primary coverage, covered charges billed separately by the anesthesiologist, radiologist and pathologist will be paid in full by the Medical/Surgical Program. Services provided by other nonparticipating providers are subject to deductible and coinsurance. Emergency care in a hospital emergency department is covered as follows: • An attending emergency department physician is paid in full • Evaluation and management emergency care billed by an attending emergency department physician is paid in full • Participating or nonparticipating providers who administer or interpret radiological exams, laboratory tests, electrocardiogram exams and/or pathology are paid in full • Other participating providers are paid in full • Other nonparticipating providers (e.g., surgeons) are considered under the Basic Medical Program and are not subject to deductible and coinsurance The Empire Plan provides additional protections to limit out-of-pocket expenses for patients who receive services from nonparticipating (non-network) providers at a network facility without their knowledge. See or contact the Medical/Surgical Program for more information. Out-of-Network Reimbursement Disclosures AAG-PA-1/19 7

10 Medical/Surgical Program Call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) PRESS 1 OR SAY and press or say 1 to reach the Medical/Surgical Program The Medical/Surgical Program covers services received from a physician or other practitioner licensed to provide medical/surgical services. It also covers services received from facilities not covered under the Hospital Program, such as outpatient surgical centers, imaging centers, laboratories, cardiac rehabilitation centers, urgent care centers and convenience care clinics. Services and supplies must be covered and medically necessary, as defined in the current version of your Empire Plan Certificate or as amended in subsequent Certificate Amendments. Call the Medical/Surgical Program if you have questions about coverage, benefits or the status of a provider. Participating Provider Program The Participating Provider Program provides medical/surgical benefits for services/supplies received from a provider that participates in The Empire Plan network. When you receive covered services from a participating provider, you pay only applicable copayments. Women’s health care services, many preventive care services and certain other covered services are paid in full (see pages 9-11). The Plan does not guarantee that participating providers are available in all specialties or geographic locations. Basic Medical Program The Basic Medical Program provides benefits for services/supplies received from a provider that does not participate in The Empire Plan network. Your out-of-pocket costs are higher when you use a nonparticipating provider. Combined annual deductible: The combined annual deductible must be satisfied before The Empire Plan pays benefits (see page 3). Coinsurance: The Empire Plan pays 80 percent of the usual and customary rate for covered services after you meet the combined annual deductible. You are responsible for the balance. After the combined annual coinsurance maximum is reached, Combined annual coinsurance maximum: The Empire Plan pays 100 percent of the usual and customary rate for covered services (see page 3). Usual and Customary Rate (UCR): The lowest of the actual charge, the provider’s usual charge or the © usual charge within the same geographic area. The Empire Plan generally utilizes FAIR Health rates at the th 90 percentile to determine the allowable amount. You can estimate the anticipated out-of-pocket cost for out-of-network services by contacting your provider for the amount that will be charged, or by visiting www.fairhealthconsumer.org to determine the UCR for these services in your geographic area or ZIP code. Basic Medical Provider Discount Program If The Empire Plan is your primary insurance coverage and you use a nonparticipating provider who is part of The Empire Plan MultiPlan group, your out-of-pocket expense will, in most cases, be reduced. Your share of the cost will be based on the lesser of The Empire Plan MultiPlan fee schedule or the usual and customary rate. The Empire Plan MultiPlan provider will submit bills to and receive payments directly from UnitedHealthcare. You are only responsible for the applicable deductible and coinsurance amounts. To find a provider, call the Medical/Surgical Program or go to www.cs.ny.gov/employee-benefits. (Retirees select Click here for NYSHIP Online for RETIREES.) Choose your group and plan, if prompted, and select Find a Provider. AAG-PA-1/19 8

11 Office Visit/Office Surgery, Laboratory/Radiology and Contraceptives Basic Medical Program Participating Provider Program Covered services provided by or received from Office visits, including office surgery, may be subject a nonparticipating provider are subject to Basic to a single $25 copayment per visit. A single, separate Medical Program benefits, including deductible $25 copayment may apply to laboratory services, and coinsurance. radiology services and/or certain immunizations provided during the office visit. The costs of U.S. Food and Drug Administration (FDA)-approved contraceptive methods for women, including sterilization, that require physician intervention, are covered and are not subject to a copayment. Certain visits and laboratory/radiology services are not subject to copayment, including well-child care, prenatal care and visits for preventive care and women’s health care. Routine Health Exams Participating Provider Program Basic Medical Program Preventive routine health exams are paid in full. Routine health exams are covered for active employees age 50 or older and for an active employee’s spouse/ Other covered services received during a routine domestic partner age 50 or older. This benefit is not health exam may be subject to copayment(s). subject to deductible or coinsurance. Covered services, such as laboratory tests and screenings provided during a routine exam that fall outside the scope of a routine exam, are subject to deductible and coinsurance. For further information, contact the Medical/Surgical Program. Adult Immunizations Participating Provider Program Basic Medical Program The following adult immunizations are paid in full, based Not covered. on recommendations by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention: • Influenza (flu)* • Pneumococcal (pneumonia)* • Measles, mumps, rubella (MMR) • Varicella (chickenpox) • Tetanus, diphtheria, pertussis (Td/Tdap) • Hepatitis A • Hepatitis B • Human papillomavirus (HPV) • Meningococcal (meningitis)* • Herpes zoster (shingles)* - Shingrix® No copayment is required for enrollees age 50 and older. - Zostavax® No copayment for enrollees age 60 and older; enrollees between the ages of 55 and 59 are subject to a $5 copayment at a network pharmacy or a $25 copayment at a physician’s office. AAG-PA-1/19 9

12 Participating Provider Program Other immunizations may be subject to a copayment. * Paid in full under the Prescription Drug Program at pharmacies that participate in CVS Caremark’s national vaccine network, subject to age limitations. See page 17 for vaccinations covered under the Prescription Drug Program. Routine Pediatric Care • Up to age 19 Participating Provider Program Basic Medical Program Routine well-child care is a paid-in-full benefit. This Provider services for Routine newborn child care: includes examinations, immunizations and the cost routine care of a newborn child are covered and not of oral and injectable substances (including the subject to deductible or coinsurance. influenza vaccine) when administered according Routine pediatric care: Routine pediatric care to pediatric immunization guidelines. rendered by a nonparticipating provider is subject to Basic Medical Program benefits, including deductible and coinsurance. Outpatient Surgical Locations Participating Provider Program Basic Medical Program A $50 copayment covers facility, same-day on-site Covered services provided by a nonparticipating testing, laboratory services provided on-site and outpatient surgical center are subject to Basic Medical anesthesiology charges for covered services at a Program benefits, including deductible and coinsurance. participating outpatient surgical center. Hospital and hospital-based outpatient surgical locations are covered under the Hospital Program (see Outpatient Department or Hospital Extension Clinic , page 6). Diabetes Education Centers Participating Provider Program Basic Medical Program Visits to a Diabetes Education Center are subject to Visits to a nonparticipating Diabetes Education a $25 copayment. Center are subject to Basic Medical Program benefits, including deductible and coinsurance. To find a Center, call the Medical/Surgical Program or go to NYSHIP Online at www.cs.ny.gov/employee-benefits. (Retirees select Click here for NYSHIP Online for RETIREES.) Choose your group and plan, if prompted, select Find a Provider and then The Empire Plan Medical/Surgical Provider Directory. Prostheses and Orthotic Devices Participating Provider Program Basic Medical Program Prostheses/orthotic devices that meet the individual’s Prostheses/orthotic devices that meet the individual’s functional needs are subject to Basic Medical Program functional needs are paid in full when obtained from benefits, including deductible and coinsurance. a participating provider. AAG-PA-1/19 10

13 Hearing Aids Basic Medical Program Hearing aids, when prescribed by a licensed provider, including evaluation, fitting and purchase, are covered under the Basic Medical Program, up to a maximum reimbursement of $1,500 per hearing aid, per ear, once every four years. Children age 12 and under are covered up to $1,500 per hearing aid, per ear, once every two years if the existing hearing aid can no longer compensate for the child’s hearing loss. This benefit applies whether you use a participating or nonparticipating provider and is not subject to deductible or coinsurance. Wigs Basic Medical Program Wigs are covered under the Basic Medical Program benefit, up to a $1,500 lifetime maximum, when hair loss is due to a chronic or acute medical condition. This benefit applies whether you use a participating or nonparticipating provider and is not subject to deductible or coinsurance. External Mastectomy Prostheses Basic Medical Program One single or double external mastectomy prosthesis is covered under the Basic Medical Program, once per calendar year. This benefit applies whether you use a participating or nonparticipating provider and is not subject to deductible or coinsurance. You must call the Medical/Surgical Program and select the Home Care Advocacy Program for precertification of any single prosthesis costing $1,000 or more. For a prosthesis requiring prior approval, benefits will be available for the most cost-effective prosthesis that meets an individual’s functional needs. Gender Dysphoria Treatment Participating Provider and Basic Medical Programs Coverage includes cross-sex hormone therapy, puberty suppressing medications and laboratory testing to monitor the safety of hormone therapy. This benefit also includes certain surgical treatments when medically necessary. Services related to gender dysphoria treatment that are cosmetic in nature are not covered. Emergency Ambulance Service Basic Medical Program Local commercial ambulance transportation is a covered basic medical expense subject only to a $70 copayment. Volunteer ambulance transportation will continue to be reimbursed for donations at the current rates of $50 for under 50 miles and $75 for over 50 miles. This benefit applies whether you use an ambulance service that is a participating provider or a nonparticipating provider and is not subject to deductible or coinsurance. AAG-PA-1/19 11

14 Managed Physical Medicine Program Administered by Managed Physical Network (MPN) Chiropractic Treatment, Physical Therapy and Occupational Therapy (when you don’t use MPN) Non-network Coverage (when you use MPN) Network Coverage $250 enrollee; $250 enrolled Annual deductible: Each office visit to an MPN provider is subject to a spouse/domestic partner; $250 all dependent $25 copayment. Related radiology and diagnostic children combined. This deductible is separate laboratory services billed by the MPN provider are from the combined annual deductible. subject to a separate $25 copayment. No more than two copayments per visit will be assessed. The Empire Plan pays up to 50 percent Coinsurance: of the network allowance after you meet the annual MPN guarantees access to network benefits. If there deductible. There is no coinsurance maximum. are no network providers in your area, you must Coinsurance under the Managed Physical Medicine contact MPN prior to receiving services to arrange Program does not contribute to and is separate from the for network benefits. combined annual coinsurance maximum. The network allowance generally equates to 18 percent of FAIR © Health Usual and Customary professional rates.* Home Care Advocacy Program (HCAP) Home Care Services, Skilled Nursing Services and Durable Medical Equipment/Supplies YOU MUST CALL for prior authorization (when you don’t use HCAP) Non-network Coverage Network Coverage (when you use HCAP) The first 48 hours of nursing care are not covered. To receive a paid-in-full benefit, you must call The After you meet the combined annual deductible (see Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) page 3), The Empire Plan pays up to 50 percent of and choose the Medical/Surgical Program, then the HCAP network allowance for covered services, Benefits Management Program, to precertify and help durable medical equipment and supplies. There is no make arrangements for covered services, durable coinsurance maximum. You are also covered for one medical equipment and supplies, including one pair of pair of diabetic shoes per year that are paid up to diabetic shoes per year, insulin pumps, Medi-Jectors 75 percent of the HCAP network allowance with a and enteral formulas. Diabetic shoes have an annual $500 annual maximum. The network allowance maximum benefit of $500. © generally equates to 33 percent of FAIR Health For diabetic supplies (except insulin Exceptions: Usual and Customary professional rates.* pumps and Medi-Jectors), call The Empire Plan Diabetic Supplies Pharmacy at 1-800-321-0591. For ostomy supplies, call Byram Healthcare Centers at 1-800-354-4054. Important: If Medicare is your primary coverage and you do not use a Medicare contract provider, your benefits will be reduced. If Medicare is your primary coverage and you live in an area or need supplies while visiting an area that participates in the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program, you must use a Medicare-approved supplier. Most of New York State is affected by DMEPOS. To locate a Medicare contract supplier, visit www.medicare.gov/supplierdirectory/ search.html or contact The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Medical/ Surgical Program, then Benefits Management Program/Home Care Advocacy Program. * Legislatively, the Department of Financial Services for the State of New York defines the term “Usual and © th Customary Rate (UCR)” as the 80 rates. percentile of the FAIR Health AAG-PA-1/19 12

15 Mental Health And Substance Abuse Program For the highest level of benefits, call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) PRESS 3 OR SAY and press or say 3 to reach the Mental Health and Substance Abuse Program Call the Mental Health and Substance Abuse Program before seeking services from a mental health care or substance use care provider, including treatment for alcoholism. Some services require precertification to confirm medical necessity before starting treatment (refer to your current for more Empire Plan Certificate information). The Clinical Referral Line is available 24 hours a day, every day of the year. You will receive the highest level of benefits when you follow the Program requirements for network coverage. You have guaranteed access to network benefits if you contact the Mental Health and Substance Abuse Program before you receive services. In an emergency, go to the nearest hospital emergency department. You or your designee should call the Mental Health and Substance Abuse Program within 48 hours of an admission for emergency care or as soon as reasonably possible. Network Coverage You pay only applicable copayments for covered services provided by a provider or facility that is in The Empire Plan network. No deductible or coinsurance applies. Non-network Coverage When you use a provider or facility that is not in The Empire Plan network, your out-of-pocket costs are higher, as described in this section. Inpatient Services You should call before an admission to a mental health care or substance use care facility to ensure that benefits are available. In the case of an emergency admission, certification should be requested as soon as possible. Network facilities are responsible for obtaining precertification. If you use a non-network facility, you may be required to pay the full cost of any stay determined not to be medically necessary. Non-network Coverage Network Coverage You will be responsible for a coinsurance amount Inpatient stays in an approved network facility are of 10 percent of billed charges, up to the combined paid in full. annual coinsurance maximum (see page 3). When the combined annual coinsurance maximum is met, you will receive network benefits. Practitioner treatment or consultation: Covered Covered Practitioner treatment or consultation: treatment or consultation services that you receive treatment or consultation services that you receive while you are an inpatient that are billed by a while you are an inpatient that are billed by a practitioner – not the facility – are subject to practitioner – not the facility – are paid in full. deductible and coinsurance as described under Office Visits and Other Outpatient Services , page 14. Ambulance Service Ambulance service to a facility where you will be receiving mental health care or substance use care is covered at no cost to you when medically necessary. Volunteer ambulance transportation is subject to copayments. Outpatient Services Hospital Emergency Department Non-network Coverage Network Coverage Network coverage applies to emergency department You pay one $100 copayment per visit to an visits at a non-network hospital. emergency department. The copayment is waived if you are admitted as an inpatient directly from the emergency department. AAG-PA-1/19 13

16 Office Visits and Other Outpatient Services Network Coverage Non-network Coverage Office visits and other outpatient services, such as The combined annual Combined annual deductible: outpatient substance use rehabilitation programs, deductible must be satisfied before The Empire Plan psychological testing/evaluation, electroconvulsive pays benefits (see page 3). therapy and Applied Behavior Analysis (ABA) services, Coinsurance: The Empire Plan pays 80 percent of may be subject to a $25 copayment per visit. the usual and customary rate for covered services Up to three visits per crisis are paid in full for after you meet the combined annual deductible. You mental health care treatment. After the third visit, are responsible for the balance. the $25 copayment per visit applies. Combined annual coinsurance maximum: After the combined annual coinsurance maximum is reached, The Empire Plan pays benefits for covered services at 100 percent of the usual and customary rate (see page 3). Usual and Customary Rate (UCR): The lowest of the actual charge, the provider’s usual charge or the usual charge within the same geographic area. The Empire Plan generally utilizes FAIR © th Health rates at the 90 percentile to determine the allowable amount. You can estimate the anticipated out-of-pocket cost for out-of-network services by contacting your provider for the amount that will be charged, or by visiting www.fairhealthconsumer.org to determine the UCR for these services in your geographic area or ZIP code. AAG-PA-1/19 14

17 Prescription Drug Program Call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) PRESS 4 OR SAY and press or say 4 to reach the Prescription Drug Program This section DOES NOT APPLY if you are enrolled in Empire Plan Medicare Rx, the Medicare Part D prescription drug program (see page 19). The Prescription Drug Program provides coverage for prescriptions for covered drugs, up to a 90-day supply, when filled at network, mail service, specialty or non-network pharmacies. Copayments You have the following copayments for covered drugs purchased from a network pharmacy, the mail service pharmacy or the designated specialty pharmacy. Up to a 30-day 31- to 90-day 31- to 90-day Supply from a Network Supply from the Mail Supply from a Drug Category Pharmacy, the Mail Service Pharmacy or the Network Service Pharmacy or the Specialty Pharmacy Pharmacy Specialty Pharmacy Level 1 Drugs or for Most $5 $10 $5 Generic Drugs Level 2 Drugs, Drugs Preferred $25 $50 $50 or Compound Drugs Level 3 Drugs or $90 $90 $45 Drugs Non-preferred Drugs not Subject to Copayment Certain covered drugs do not require a copayment when using a network pharmacy: • Oral chemotherapy drugs, when prescribed for the treatment of cancer • Generic oral contraceptive drugs and devices or brand-name contraceptive drugs/devices without a generic equivalent (single-source brand-name drugs/devices) • Tamoxifen and raloxifene, when prescribed for the primary prevention of breast cancer • Certain preventive adult vaccines when administered by a licensed pharmacist at a pharmacy that participates in the CVS Caremark national vaccine network • Certain prescription and over-the-counter medications considered preventive under the Patient Protection and Affordable Care Act Brand-name Drugs with Generic Equivalent The difference Ancillary Charge: If you choose to purchase a covered brand-name drug that has a generic in cost between the brand-name equivalent, you will pay the Level 3 non-preferred drug copayment plus drug and the generic equivalent. the ancillary charge, not to exceed the full retail cost of the covered drug. Exceptions • If the brand-name drug has been placed on Level 1 of The Empire Plan Flexible Formulary, you will pay the Level 1 copayment. • You pay only the applicable copayment for the following Level 3 brand-name drugs with generic equivalents: Coumadin, Dilantin, Lanoxin, Levothroid, Mysoline, Premarin, Synthroid, Tegretol and Tegretol XR. One copayment covers up to a 90-day supply. AAG-PA-1/19 15

18 Flexible Formulary Drug List The Empire Plan Prescription Drug Program has a flexible formulary drug list for prescription drugs. The Empire Plan Flexible Formulary is designed to provide enrollees and the Plan with the best value in prescription drug spending. This is accomplished by: Excluding coverage for certain brand-name or generic drugs if the drug has no clinical advantage over other • covered medications in the same therapeutic class. Placing a brand-name drug on L • evel 1 or excluding or placing a generic drug on Level 3, subject to the appropriate copayment. These placements may be revised mid-year when such changes are advantageous to The Empire Plan. Enrollees will be notified in advance of such changes. Applying the highest copayment to non-preferred drugs that provide no clinical advantage over two or more • L evel 1 drug alternatives in the same therapeutic class. This may result in no Level 2 brand-name drugs. Including utilization management tools to promote transparency and reduce costs, not limited to generic • substitution, prior authorization and physician education. Prior Authorization Drugs You must have prior authorization for certain drugs, including generic equivalents, noted with "PA" on the Empire Plan Flexible Formulary. Certain medications also require prior authorization based on age, gender or quantity limit specifications. Compound drugs that have a claim cost to the Program that exceeds $200 will also require prior authorization. The drugs that require prior authorization are subject to change as drugs are approved by the U.S. Food and Drug Administration (FDA), introduced into the market or approved for additional indications. For information about prior authorization requirements, or the current list of drugs requiring authorization, call the Click rug Program or go to NYSHIP Online at w ww.cs. ny.gov/employee- benefits. (Retirees select D Prescription ur Benefits and Yo here for NYSHIP Online for RETIREES.) Choose your group and plan, if prompted, select Using then 2019 Drugs th at Require Prior Aut horization. Excluded Drugs Certain brand-name and generic drugs are excluded from The Empire Plan Flexible Formulary if they have The 2019 Empire Plan no clinical advantage over other covered medications in the same therapeutic class. Flexible Formulary drug list includes drugs that are excluded in 2019, along with suggested alternatives. New prescription drugs may be subject to exclusion when they first become available on the market. For a complete list of Excluded Drugs, call the Prescription Drug Program or go to NYSHIP Online at www.cs.ny.gov/ employee-benefits. (Retirees select Click here for NYSHIP Online for RETIREES.) Choose your group and plan, if prompted, select Using Your Benefits and then 2019 Excluded Drug List. Also check the website for current information regarding exclusions of newly launched prescription drugs. Medical Exception Program for Excluded Drugs A medical exception program* is available for non-formulary drugs that are excluded from coverage. o request a medical exception, you and your physician must first evaluate whether covered drugs on the T Flexible Formulary are appropriate alternatives for your treatment. After an appropriate trial of formulary alternatives, your physician may submit a letter of medical necessity to CVS Caremark that details the formulary alternative trials and any other clinical documentation supporting medical necessity. The physician can fax the exception request to CVS Caremark at 1-888-487-925 7. If an exception is approved, the Level 1 copayment will apply for generic drugs and the Level 3 copayment will apply for brand-name drugs. Note: Drugs that are only FDA approved for cosmetic indications are excluded from the Plan and are not eligible for a medical exception. * If you are Medicare primary, refer to your Empire Plan Medicare Rx plan materials for information regarding your appeal rights and the process to follow. AAG-PA-1/19 16

19 Types of Pharmacies Network Pharmacy A network pharmacy is a retail pharmacy that participates in the CVS Caremark network. When you visit a network pharmacy to fill a prescription, you pay a copayment (and ancillary charge, if applicable). To find a retail network pharmacy location that participates in the CVS Caremark network, call the Prescription Drug Program or go to NYSHIP Online at www.cs.ny.gov/employee-benefits. (Retirees select Click here for NYSHIP Online for RETIREES.) Choose your group and plan, if prompted, and select Find a Provider. CVS Caremark National Vaccine Network Pharmacy Select preventive vaccines are covered without copayment when administered at a pharmacy that participates in the CVS Caremark national vaccine network. Vaccines available in a pharmacy are: • Influenza (flu) • Meningococcal (meningitis) requires prescription • Herpes zoster (shingles)* – • Pneumococcal (pneumonia) To find out if a pharmacy participates in the CVS Caremark national vaccine network, call the Prescription Drug Program or visit www.empireplanrxprogram.com and select CVS Caremark, then Find a Local Pharmacy. Be sure to select Vaccine network under Advanced Search. Only certain pharmacies are part of the CVS Caremark national vaccine network. Call the pharmacy in advance to verify availability of the vaccine. * Zostavax® is covered with no copayment for individuals 60 and older and for a $5 copayment for ages 55 to 59. Shingrix® is covered for individuals 50 and older at no copayment. Mail Service Pharmacy You may fill your prescription by mail through the CVS Caremark Mail Service Pharmacy by using the mail order form. For forms and refill orders, call the Prescription Drug Program. To refill a prescription on file with the mail service pharmacy, you may order by phone or online at www.empireplanrxprogram.com or download forms on NYSHIP Online at www.cs.ny.gov/employee-benefits. (Retirees select Click here for NYSHIP Online for RETIREES.) Choose your group and plan, if prompted. Select Forms and scroll down to the CVS Caremark Mail Service Order Form. Specialty Pharmacy Program The Empire Plan Specialty Pharmacy Program offers individuals using specialty drugs enhanced services, including: • Refill reminder calls • Disease education • Expedited, scheduled delivery of your medications • Drug education at no additional charge • Compliance management • All necessary supplies, such as needles and • Side-effect management syringes applicable to the medication • Safety management Prior authorization is required for some specialty medications. To get started with the CVS Caremark Specialty Pharmacy, to request refills or to speak to a specialty-trained pharmacist or nurse, please call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) Monday through Friday between 7:30 a.m. and 9 p.m. Eastern time. Choose the Prescription Drug Program, and ask to speak with Specialty Customer Care. If your call is urgent, you may request an on-call pharmacist 24 hours a day, seven days a week. A complete list of specialty medications included in the Specialty Pharmacy Program is available on NYSHIP Online at www.cs.ny.gov/employee-benefits. (Retirees select Click here for NYSHIP Online for RETIREES.) Choose your group and plan, if prompted, select Using Your Benefits and then Specialty Pharmacy Drug List. Non-network Pharmacy If you do not use a network pharmacy, or if you do not use your Empire Plan benefit card at a network pharmacy, you must submit a claim for reimbursement to: The Empire Plan Prescription Drug Program, c/o CVS Caremark, P.O. Box 52136, Phoenix, AZ 85072-2136. In most cases, you will not be reimbursed the total amount you paid for the prescription. • If your prescription was filled with a generic drug or a covered brand-name drug with no generic equivalent, you will be reimbursed up to the amount the Program would reimburse a network pharmacy for that prescription, less your copayment. AAG-PA-1/19 17

20 • If your prescription was filled with a covered brand-name drug that has a generic equivalent, you will be reimbursed up to the amount the Program would reimburse a network pharmacy for filling the prescription with that drug’s generic equivalent, less your copayment, unless the brand-name drug has been placed on Level 1 of The Empire Plan Flexible Formulary. Elimination of New to You Prescription Drug Requirement The 30-day quantity limit for maintenance medications required by the New to You Program has been eliminated for 2019. You are able to get up to a 90-day supply without having to fill two prescriptions at a 30-day quantity first. The removal of this requirement gives you and your doctor greater flexibility in managing your medications prescribed for your conditions and helps lower out-of-pocket expenses. If you have any questions about how this will affect your medications, you may call The Empire Plan’s toll-free number at 1-877-7-NYSHIP (1-877-769-7447) and press or say 4 for the Prescription Drug Program. AAG-PA-1/19 18

21 Empire Plan Medicare Rx Prescription Drug Program Call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) PRESS 4 OR SAY and press or say 4 to reach the Prescription Drug Program This section ONLY applies to Medicare-primary enrollees and dependents enrolled in Empire Plan Medicare Rx. Empire Plan Medicare Rx is a Medicare Part D plan with expanded coverage designed specifically for Medicare- primary Empire Plan enrollees and dependents. Eligible individuals are automatically enrolled in Empire Plan Medicare Rx. Prior to enrollment, affected enrollees and dependents receive important information from SilverScript. Each Medicare-primary enrollee and Medicare-primary dependent will receive a unique Empire Plan Medicare Rx ID card from SilverScript to use at network pharmacies. You have coverage for prescriptions for covered drugs, up to a 90-day supply, when filled at network, non- network or mail service pharmacies. If you have questions, call the Prescription Drug Program or visit www.empireplanrxprogram.com. Copayments You have the following copayments for drugs purchased from a network pharmacy, the mail service pharmacy or the designated specialty pharmacy. Up to a 30-day (One 31- to 90-day 31- to 90-day Supply Month) Supply of a of a Covered Drug Supply of a Covered Drug from a from the Mail Service Covered Drug Drug Category Network Pharmacy, the from a Network Pharmacy or the Mail Service Pharmacy or Specialty Pharmacy Pharmacy the Specialty Pharmacy Tier 1 Drugs. Includes $5 $10 $5 Most Generic Drugs Tier 2 Drugs. Includes $50 $50 $25 Drugs Preferred Brand Tier 3 Drugs. Includes Non- $90 $90 $45 Brand-name Drugs preferred Drugs not Subject to Copayment Certain covered drugs do not require a copayment: • Oral chemotherapy drugs, when prescribed for the treatment of cancer • Generic oral contraceptive drugs and devices or brand-name contraceptive drugs/devices without a generic equivalent (single-source brand-name drugs/devices) • Tamoxifen and raloxifene, when prescribed for the primary prevention of breast cancer AAG-PA-1/19 19

22 Covered Drugs Empire Plan Medicare Rx uses a formulary of Medicare Part D covered drugs and a secondary list of additional (non-Part D) covered drugs. Since Medicare Part D plans do not cover all types of drugs, the secondary list enhances the Medicare Part D covered drugs so that the coverage closely mirrors the drugs covered under The Empire Plan Flexible Formulary for non-Medicare enrollees. The 2019 Empire Plan Medicare Rx Abridged Formulary is sent to all current members on an annual basis. It is included in an enrollment kit that Medicare-primary Empire Plan enrollees and dependents receive from SilverScript prior to enrolling in Empire Plan Medicare Rx. The 2019 Empire Plan Medicare Rx Comprehensive Formulary, a complete list of covered drugs, is also available online at www.empireplanrxprogram.com. If you have questions regarding the prescription drugs covered under Empire Plan Medicare Rx, call the Prescription Drug Program. Note: Certain drugs are covered under Medicare Part B or Medicare Part D depending upon the circumstances for use. Additional information may be needed from the prescribing physician describing the use and setting of the drug to determine coverage under Medicare Part B or Medicare Part D. Prescription medications covered under Medicare Part B that are dispensed by a network pharmacy are subject to 20 percent coinsurance under Medicare and automatically crossed over to the Empire Plan Medical/Surgical Program for reimbursement. Please allow 4-6 weeks for reimbursement. Empire Plan Medicare Rx ID Cards Every Medicare-primary enrollee and every Medicare-primary dependent enrolled in Empire Plan Medicare Rx receives a separate, individualized prescription drug ID card from SilverScript. Each card provides a new unique ID number you can use at a network pharmacy when you fill your prescription medications. If you have questions, call the Prescription Drug Program. Sample Empire Plan Medicare Rx ID card: Sample Empire Plan card: Continue to use your Empire Plan card for all other Empire Plan benefits including hospital services, medical/surgical services, mental health and substance abuse services and prescriptions covered under Medicare Part B. Enrollees and dependents who are not Medicare primary will continue to use this card for their prescription drugs. AAG-PA-1/19 20

23 Prior Authorization Program Certain medications require prior authorization based on diagnosis, clinical condition or quantity limit specifications. For information about prior authorization requirements, or the current list of drugs requiring authorization, call the Prescription Drug Program. Types of Pharmacies Network Pharmacy A network pharmacy is a retail pharmacy that participates in the CVS Caremark network. When you visit a network pharmacy to fill a prescription, you pay a copayment (and ancillary charge, if applicable). To find a retail network pharmacy location that participates in the CVS Caremark network, call the Prescription Drug Program or go to NYSHIP Online at www.cs.ny.gov/employee-benefits. (Retirees select Click here for NYSHIP Online for RETIREES.) Choose your group and plan, if prompted, and select Find a Provider. Mail Service Pharmacy You may fill your prescription by mail through the CVS Caremark Mail Service Pharmacy by using the mail order form. For forms and refill orders, call the Prescription Drug Program. To refill a prescription on file with the mail service pharmacy, you may order by phone or online at www.empireplanrxprogram.com. Specialty Pharmacy Program The Empire Plan Specialty Pharmacy Program offers individuals using specialty drugs enhanced services including: • Refill reminder calls • Disease education • Expedited, scheduled delivery of your medications • Drug education at no additional charge • Compliance management • All necessary supplies, such as needles and • Side-effect management syringes applicable to the medication • Safety management For a complete list of specialty medications included in the Specialty Pharmacy Program, visit www.empireplanrxprogram.com. Prior authorization is required for some specialty medications. To get started with the CVS Caremark Specialty Pharmacy, to request refills or to speak to a specialty-trained pharmacist or nurse, please call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) Monday through Friday between 7:30 a.m. and 9 p.m. Eastern time. Choose the Prescription Drug Program, and ask to speak with Specialty Customer Care. If your call is urgent, you may request an on-call pharmacist 24 hours a day, seven days a week. Non-network Pharmacy If you do not use a network pharmacy, or if you do not use your Empire Plan Medicare Rx benefit card at a network pharmacy, you must submit a claim for reimbursement to: The Empire Plan Medicare Rx Prescription Drug Program, c/o CVS Caremark, P.O. Box 52066, Phoenix, AZ 85072-2066. In most cases, you will not be reimbursed the total amount you paid for the prescription. This plan will process out-of-network paper claim member reimbursements at 100 percent submitted charges less the enrollee’s copayment. AAG-PA-1/19 21

24 Benefits on the Web NYSHIP Online is a complete resource for your health insurance benefits, including: • Current publications describing your benefits and plan • Announcements • An event calendar • Prescription drug information • Contact information • Links to all Empire Plan program administrator websites To find the most up-to-date information about your health insurance coverage, go to NYSHIP Online at www.cs.ny.gov/employee-benefits. (Retirees select Click here for NYSHIP Online for RETIREES.) Choose your group and plan, if prompted, to get to the NYSHIP Online homepage. You can bookmark this page to bypass the login screen the next time you sign in. AAG-PA-1/19 22

25 Contact Information Call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and select the appropriate program. Medical/Surgical Program: Administered by UnitedHealthcare PRESS Representatives are available Monday through Friday, 8 a.m. to 4:30 p.m. Eastern time. OR SAY TTY: 1-888-697-9054 P.O. Box 1600, Kingston, NY 12402-1600 Claims submission fax: 845-336-7716 1 Online submission: https://nyrmo.optummessenger.com/public/opensubmit Hospital Program: Administered by Empire BlueCross BlueShield Administrative services are provided by Empire HealthChoice Assurance, Inc., a licensee of the BlueCross and BlueShield Association, an association of independent BlueCross and BlueShield plans. PRESS OR SAY Representatives are available Monday through Friday, 8 a.m. to 5 p.m. Eastern time. TTY: 1-800-241-6894 2 New York State Service Center, P.O. Box 1407, Church Street Station, New York, NY 10008-1407 Online form: www.empireblue.com/forms/ Claims submission fax: 888-367-9788 Administered by Beacon Health Options, Inc. Mental Health and Substance Abuse Program: PRESS Representatives are available 24 hours a day, seven days a week. OR SAY TTY: 1-855-643-1476 P.O. Box 1850, Hicksville, NY 11802 Claims submission fax: 855-378-8309 3 Online form: www.achievesolutions.net/achievesolutions/en/empireplan/Home.do Prescription Drug Program: Administered by CVS Caremark Representatives are available 24 hours a day, seven days a week. TTY: 711 PRESS Customer Care Correspondence, P.O. Box 6590, Lee’s Summit, MO 64064-6590 OR SAY 4 Medicare Rx Prescription Drug Program TTY: 711 SilverScript Insurance Company, P.O. Box 52067, Phoenix, AZ 85072-2067 PRESS SM Empire Plan NurseLine : Administered by UnitedHealthcare OR SAY Registered nurses are available 24 hours a day, seven days a week to answer health-related questions. 5 This document provides a brief look at Empire Plan benefits for Participating Agency enrollees. Use it with your NYSHIP General Information Book, Empire Plan Certificate and Empire Plan Reports . If you have questions, call 1-877-7-NYSHIP (1-877-769-7447) and choose the program you need. New York State Department of Civil Service Employee Benefits Division, Albany, New York 12239 518-457-5754 or 1-800-833-4344 (U.S., Canada, Puerto Rico, Virgin Islands) www.cs.ny.gov The Empire Plan At A Glance is published by the Employee Benefits Division of the New York State Department of Civil Service. The Employee Benefits Division administers the New York State Health Insurance Program (NYSHIP). NYSHIP provides your health insurance benefits through The Empire Plan. AAG-PA-1/19 23

26 Save this document New York State Department of Civil Service Employee Benefits Division P.O. Box 1068 Schenectady, New York 12301-1068 www.cs.ny.gov Information for the Enrollee, Enrolled Spouse/ Domestic Partner and Other Enrolled Dependents Participating Agencies At A Glance – January 2019 Please do not send mail or correspondence to the return address above. See boxed address page 23. ! It is the policy of the New York State 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 NYSHIP Online at www.cs.ny.gov/ employee-benefits. Visit 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 Health Benefits Administrator (HBA). COBRA Enrollees: Contact your former HBA. G-PA-1/19 AA This document was printed using recycled paper and environmentally sensitive inks. PA0212 The Empire Plan Copayments at a Glance The listed copayments apply when services are received under the Participating Provider Program or network coverage. Preventive care services under the Patient Protection and Affordable Care Act, women’s health care services and certain other covered services are not subject to copayment. , radiology, diagnostic laboratory tests, Office visit, office surgery $25 copayment – freestanding cardiac rehabilitation center visit, convenience care clinic visit Urgent care center visit $30 copayment – Medical/Surgical $50 copayment – Non-hospital outpatient surgical locations Program $70 copayment – Licensed ambulance service Chiropractic treatment or physical therapy services (Managed Physical Medicine Program) Office visit, radiology , diagnostic laboratory tests $25 copayment – – Outpatient physical therapy $25 copayment $50 copayment – Urgent care center visit, outpatient services for diagnostic radiology and diagnostic laboratory tests Hospital Program $95 copayment – Outpatient surgery $100 copayment – Emergency department visit Visit to an outpatient substance use treatment program $25 copayment – Mental Health $25 copayment Visit to a mental health professional – and Substance Emergency department visit $100 copayment – Abuse Program Up to a 90-day supply from a network pharmacy, the mail service pharmacy or the designated Prescription specialty pharmacy (see The Empire Plan Prescription Drug Program copayment chart on Drug Program page 15 or the Empire Plan Medicare Rx Program copayment chart on page 19). AAG-PA-1/19 24

Related documents

CityNT2019TentRoll 1

CityNT2019TentRoll 1

STATE OF NEW YORK 2 0 1 9 T E N T A T I V E A S S E S S M E N T R O L L PAGE 1 VALUATION DATE-JUL 01, 2018 COUNTY - Niagara T A X A B L E SECTION OF THE ROLL - 1 CITY - North Tonawanda TAX MAP NUMBER ...

More info »
RIE Tenant List By Docket Number

RIE Tenant List By Docket Number

SCRIE TENANTS LIST ~ By Docket Number ~ Borough of Bronx SCRIE in the last year; it includes tenants that have a lease expiration date equal or who have received • This report displays information on ...

More info »
G:\COMP\PHSA\PHSA.bel

G:\COMP\PHSA\PHSA.bel

G:\COMP\PHSA\PHSA-MERGED.XML PUBLIC HEALTH SERVICE ACT [As Amended Through P.L. 115–408, Enacted December 31, 2018] References in brackets ¿ ø¿ ø are to title 42, United States Code TITLE I—SHORT TITL...

More info »
CRPT 116hrpt9 u2

CRPT 116hrpt9 u2

U:\2019CONF\HJRes31Front.xml APPRO. SEN. [COMMITTEE PRINT] REPORT { } CONGRESS 116TH 1st HOUSE OF REPRESENTATIVES Session 116- FURTHER APPROPRIATIONS FOR MAKING CONTINUING OF HOMELAND SECURITY FOR THE...

More info »
Justification Book

Justification Book

UNCLASSIFIED Department of Defense Fiscal Year (FY) 2019 Budget Estimates February 2018 Office of the Secretary Of Defense Defense-Wide Justification Book Volume 3B of 5 Research, Development, Test & ...

More info »
OperatorHoursReport

OperatorHoursReport

John Bel Edwards Rebekah E. Gee MD, MPH SECRETARY GOVERNOR State of Louisiana Louisiana Department of Health Office of Public Health Certified Water and Wastewater Operators 2018 - 2019 Hours Hours li...

More info »
OctoberCUR2018

OctoberCUR2018

CHANCELLOR'S UNIVERSITY REPORT OCTOBER 29 2018

More info »
Untitled

Untitled

Harmoniz ed vision 4 hedule of the United States (2019) Re Tariff Sc Annotated f poses ting Pur or Statistical Repor GN p .1 GENERAL R ATION ULES OF INTERPRET inciples: wing pr ollo y the f verned b i...

More info »
untitled

untitled

G:\P\16\HR1\INTRO.XML ... (Original Signature of Member) TH 116 CONGRESS 1 ST S ESSION H. R. 1 To expand Americans’ access to the ballot box, reduce the influence of big money in politics, and strengt...

More info »
NB18

NB18

Table of Contents National Board Pressure Relief Device Certificati ons NB-18 FOREWARD... 1 NATIONAL BOARD PRESSURE RELIEF DEVICE CERTIFICATION... 2 DETERMINATION OF CERTIFIED RELIEVING CAPACITIES... ...

More info »
NCDOT Current STIP

NCDOT Current STIP

May 2019 NCDOT Current STIP

More info »
June2018CUR

June2018CUR

CHANCELLOR'S UNIVERSITY REPORT JUNE 25 2018

More info »
City 2018 2019

City 2018 2019

2018–2019 CATALOG Fall 2018, Spring 2019, Summer 2019 1313 Park Blvd., San Diego, CA 92101 619-388-3400 www.sdcity.edu Ricky Shabazz, Ed.D. President San Diego City College is accredited by the Accred...

More info »
Operator Directory Listing

Operator Directory Listing

OPERATOR'S DIRECTORY SORTED BY OPERATOR NAME DATA SUPPLIED BY: FORM 1006 B CURRENT AS OF: Tuesday, April 16, 2019 Please notify Surety Department at ( 405 ) 521-2273 of any corrections or omissions th...

More info »
FactoryTalk View Site Edition User's Guide

FactoryTalk View Site Edition User's Guide

User Manual FactoryTalk View Site Edition User's Guide

More info »
G:\COMP\SBA\SBA.bel

G:\COMP\SBA\SBA.bel

G:\COMP\SBA\SMALL BUSINESS ACT.XML SMALL BUSINESS ACT [Public Law 85–536; Approved July 18, 1958] [15 U.S.C. 631 et seq.; 72 Stat. 384 et seq.] [As Amended Through P.L. 115-416, Enacted January 3, 201...

More info »
DEC CUR

DEC CUR

CHANCELLOR'S UNIVERSITY REPORT DECEMBER 10, 2018

More info »
Nios® II Software Developer's Handbook

Nios® II Software Developer's Handbook

® Nios II Software Developer's Handbook ® ® Quartus Updated for Intel Prime Design Suite: 19.1 Subscribe NII-SDH | 2019.04.30 Send Feedback Latest document on the web: PDF | HTML

More info »
Squire Patton Boggs Tariff Book

Squire Patton Boggs Tariff Book

Squire Patton Boggs Tariff Book January 11, 2019

More info »