Active Choices 2017

OCTOBER 2016
Health Insurance Choices for 2017

For employees of the State of New York, Participating Employers, their enrolled dependents,
COBRA enrollees with their NYSHIP benefits and Young Adult Option enrollees
Information & Reminders
Contents
Make Your Health Plan Choices...... i Make Your Health Plan Choices
Rates and Deadline This booklet explains the options available to you under the
for Changing Plans........................................ i New York State Health Insurance Program (NYSHIP) for your
Changing Your Pre-Tax health insurance and other elections. You may choose coverage
Contribution Program Status...............1 under The Empire Plan or one of the NYSHIP-approved health
Your Share of the Premium................. 2 maintenance organizations (HMOs) in your area. Or, if you can be
covered under other employer-sponsored group health benefits,
Let Your Agency Know
about Changes................................................ 2 you may be eligible to elect the Opt-out Program.*
If You Retire or Leave Consider your options carefully. You may not change your option
State Service in 2017................................. 2 after the deadline, except in special circumstances (see your
If You Become Eligible NYSHIP General Information Book and Empire Plan Reports
for Medicare in 2017.................................. 2 or HMO Reports for details about changing options outside the
Comparing Your Option Transfer Period). If you still have questions after you have
NYSHIP Options.............................................. 3 read the information in this booklet, contact your Health Benefits
Benefits.................................................................... 3 Administrator (HBA) or The Empire Plan program administrators
and HMOs directly.
Exclusions.............................................................. 3
Geographic Area Served...................... 3 Rates for 2017 and Deadline for Changing Plans
Terms to Know.............................................4-5 The Empire Plan and HMO rates for 2017 will be mailed to
NYSHIPs Young Adult Option......... 5 your home and posted on our web site, NYSHIP Online, as
Medicare & NYSHIP.................................... 6 soon as they are approved. To find this information online, go
Benefits Provided by All Plans.........7 to www.cs.ny.gov/employee-benefits. Next, select your group
Whats New?....................................................... 8 and plan, if prompted, and then Health Benefits & Option Transfer.
Choose Rates and Health Plan Choices.
The Empire Plan
or a NYSHIP HMO................................ 8-10 Note: Participating Employers (PEs), such as the Thruway
Summary of Benefits Authority and the Metropolitan Transportation Authority, will
and Coverage ................................................ 10 notify their enrollees of 2017 rates.
Making a Choice........................................... 11 The rate flyer announces the option-change deadline and dates
Plan Similarities that changes in health insurance payroll deductions will occur.
and Differences..................................... 12-13 You will have 30 days from the date your agency receives rate
Questions & Answers............................. 14 information to make a decision. Your HBA can help if you have
Opt-out Program.......................................... 15 questions. COBRA and Young Adult Option enrollees may contact
Plans by County.....................................16-17 the Employee Benefits Division at 518-457-5754 or 1-800-833-4344
(United States, Canada, Puerto Rico and the Virgin Islands).
The Empire Plan
Benefit Chart........................................... 18-27
NYSHIP HMO * The Opt-out Program is available to eligible NYS employees who have
Benefit Charts.......................................28-43 other employer-sponsored group health insurance. Check with your
HBA if you have any questions about your eligibility for the Opt-out
NYSHIP Online.....................................44-45 Program. Employees of Participating Employers in NYSHIP should
check with their HBA to determine if their employer offers a program
similar to the Opt-out Program. See page 15 for more information about
this program.
i CHOICES 2017 ACTIVES

Changing Your 2017 Pre-Tax PTCP ENROLLMENT LIMITS MID-YEAR CHANGES
Contribution Program (PTCP) Status Under Internal Revenue Service (IRS) rules, if you are
(November 30, 2016 Deadline) enrolled in PTCP, you may not change your pre-tax
PTCP does not apply to COBRA and Young Adult payroll deduction for health benefits during the Plan
Option enrollees or retirees. The following also year (by changing your health benefit option, changing
may not apply to Participating Employers. PEs that your coverage [Family or Individual] or by canceling
participate in a pre-tax contribution program will coverage) unless a PTCP-qualifying event occurs.
provide specific pre-tax information to their employees. Requests to change your pre-tax deduction during the
Under PTCP, your share of the health insurance tax year must be consistent (for all individuals covered
premium is deducted from your wages before taxes under the contract) with qualifying life events and must
are withheld, which may lower your tax liability. be requested within 30 days of the event. You may
not change your pre-tax payroll deduction for health
NO ACTION IS REQUIRED TO KEEP YOUR benefits (other than during the PTCP Enrollment
CURRENT PTCP STATUS. Period or Option Transfer Period), except when one
If you wish to change your PTCP selection for 2017, of the following PTCP-qualifying events occurs:
submit a signed and completed Health Insurance change in marital status
Transaction Form (PS-404) to your HBA between
change in number of dependents
November 1 and November 30, 2016.
change in your (or your dependents) employment
Checking Your PTCP Status status that affects eligibility for health benefits
Your paycheck shows whether or not you are your dependent satisfies or ceases to satisfy
enrolled in PTCP. eligibility requirements for health benefits
change in your (or your dependents) place
If you are enrolled in PTCP or part of your deduction
of residence or worksite that affects eligibility
is being taken after tax (e.g., for a non-federally
for benefits
qualifying dependent), your paycheck stub shows
significant change in health benefits and/or
Regular Before-Tax Health in the Before-Tax
premium under NYSHIP
Deductions section. Your health insurance
premium is deducted from your wages before significant change in health benefits and/or
taxes are withheld. premium under your (or your dependents)
other employers plan
If you are not enrolled in PTCP, your paycheck
stub shows Regular After-Tax Health in the COBRA events
After-Tax Deductions section. Your health judgment, decree or order to provide
insurance premium is deducted from your health benefits to eligible dependents
wages after taxes are withheld. Medicare or Medicaid eligibility
leaves of absence
NEW ENROLLEES HIPAA special enrollment rights
When enrolling in NYSHIP coverage, new enrollees A coverage change due to a qualifying event
must elect whether or not to participate in PTCP. No must be requested within 30 days of the event
election will be made automatically on the enrollees (or within the waiting period if newly eligible);
behalf. Enrollment cannot be completed without a delays may be costly.
PTCP election.
See your HBA to change your health insurance option, type of coverage or pre-tax status.
NO ACTION IS REQUIRED IF YOU DO NOT WISH TO MAKE CHANGES (unless you wish to continue
enrollment in the Opt-out Program; see page 15). Changes are not automatic, and deadlines apply. You
must report any change that may affect your coverage to your HBA. See pages 1-3 in this booklet and
your NYSHIP General Information Book for complete information.
ACTIVES CHOICES 2017 1

Your Share of the Premium

The following does not apply to employees of Participating Employers. PEs will provide premium information.
It also does not apply to COBRA enrollees, Young Adult Option enrollees or enrollees in Leave Without Pay
status (who pay the full cost of coverage).
New York State helps pay for your health insurance coverage. After the States contribution, you are
responsible for paying the balance of your premium, usually through biweekly deductions from your paycheck.
Whether you enroll in The Empire Plan or in a NYSHIP HMO, the States share and your share of the cost of
coverage are based on the following (salary requirements vary; contact your HBA for more information):
Enrollee Pay Grade Individual Coverage Dependent Coverage

State Share Employee Share State Share Employee Share
Grade 9 and below* 88% 12% 73% 27%
Grade 10 and above* 84% 16% 69% 31%
* Or salary equivalent, if no Grade assigned. Contact your HBA to confirm.
If you enroll in a NYSHIP HMO, the States dollar contribution for the hospital, medical/surgical and mental
health and substance abuse components of your HMO premium will not exceed its dollar contribution for those
components of The Empire Plan premium. For the prescription drug component of your HMO premium, the State
pays the share noted in the table; the dollar amount is not limited by the cost of Empire Plan drug coverage.
As soon as they are approved, 2017 rates will be mailed to your home and posted on NYSHIP Online at
www.cs.ny.gov/employee-benefits. Select your group and plan, if prompted, and then Health Benefits & Option
Transfer. Choose Rates and Health Plan Choices.
Let Your Agency Know about Changes If You Retire or

You must notify your HBA if your home address Leave State Service in 2017
or phone number changes. If you are an active If you continue your NYSHIP enrollment as a retiree
employee of New York State and registered for or vestee, you may change your health insurance
MyNYSHIP, you may also make address and option plan when your status changes. As a retiree or
changes online. Note: MyNYSHIP is not available vestee, you may change health insurance options at
for active employees of PEs. any time once during a 12-month period. For more
Changes in your family status, such as gaining or information on changing options as a retiree or
losing a dependent, may mean you need to change vestee, ask your HBA for 2017 Choices for Retirees.
your health insurance coverage from Individual to
Family or from Family to Individual. If you submit a
If You Become Eligible
timely request after a change in family status, you for Medicare in 2017
may make changes outside the Option Transfer If you or a dependent is eligible for Medicare because
Period without experiencing a waiting period. See of age or disability, see Medicare and NYSHIP on
your NYSHIPGeneral Information Book for details. page 6 for important information. Please read this
Promptly inform your HBA about any change to Medicare section if you or any dependent will be
ensure it is effective on the actual date of change turning 65 in 2017 or if you are planning to retire in
in family status. the coming year and will become Medicare primary.
2 CHOICES 2017 ACTIVES

Comparing Your NYSHIP Options Exclusions
Choosing the option that best meets your needs All plans contain coverage exclusions for certain
and the needs of your family requires careful services and prescription drugs.
consideration. As with most important purchases, Workers compensation-related expenses
there is more to consider than cost. and custodial care generally are excluded
The first step toward making a good choice is from coverage.
understanding the similarities and differences For details on a plans exclusions, read the Empire
among your NYSHIP options. There are two types Plan Certificate or the NYSHIP HMO contract or
of health insurance plans available to you under check with the plan directly.
NYSHIP: The Empire Plan and NYSHIP HMOs. The
Empire Plan is available to all employees. NYSHIP Geographic Area Served
HMOs are available in various geographic areas of THE EMPIRE PLAN
New York State. Depending on where you live or
Benefits for covered services, not just urgent and
work, one or several NYSHIP HMOs will be
emergency care, are available worldwide. However,
available to you. The Empire Plan and NYSHIP
access to network benefits is not guaranteed in all
HMOs are similar in many ways but also have
states and regions.
important differences.
Additionally, if you have other employer-sponsored HEALTH MAINTENANCE ORGANIZATIONS (HMOS)
group health benefits available to you, you may Coverage is available in each HMOs specific
be eligible for the Opt-out Program (see page 15 service area.
for details). An HMO may arrange for coverage of care
received outside its service area at its discretion
Benefits
in certain circumstances. See the out-of-area
THE EMPIRE PLAN AND NYSHIP HMOS benefit description on each HMO page for more
All NYSHIP plans provide a wide range of hospital, detailed information.
medical/surgical and mental health and substance
abuse coverage.
All plans provide prescription drug coverage
for those who do not receive it through a union
Employee Benefit Fund.
All plans provide coverage for certain preventive
care services as required by the federal Patient
Protection and Affordable Care Act (PPACA). For
more information on preventive care services,
visit www.hhs.gov/healthcare/rights/preventive-care
or NYSHIP Online.
Benefits differ among plans. Read this booklet and
the Empire Plan Certificate (available from your HBA)
and HMO contracts (available from each HMO)
for details.

Terms to Know
Coinsurance: The enrollees share of the cost of Health Maintenance Organization (HMO):
covered services, which is a fixed percentage of A managed care delivery system organized to deliver
covered medical expenses. health care services in a geographic area. An HMO
provides a predetermined set of benefits through
Copayment: The enrollees share of the cost of a network of selected physicians, laboratories
covered services, which is a fixed dollar amount and hospitals for a prepaid premium. Except for
paid when a medical service is received, regardless emergency services and other services approved by
of the total charge for the service. your HMO, you and your enrolled dependents may
have coverage only for services received from your
Deductible: The dollar amount an enrollee is HMOs network. See NYSHIPHealth Maintenance
required to pay before health plan benefits begin Organizations on pages 9 and 10 for more
to reimburse for services. information on HMOs.
Fee-for-service: A method of billing for health care Managed Care: A health care program designed to
services. A provider charges a fee each time an ensure you receive the highest quality medical care
enrollee receives a service. for the lowest cost in the most appropriate health
care setting. Most managed care plans require you
Formulary: A list of preferred drugs used by to select a primary care physician employed by
a health plan. A plan with a closed formulary (or who contracts with) the managed health care
provides coverage only for drugs that appear on system. He or she serves as your health care
the list. An open or incented formulary encourages manager by coordinating virtually all health care
use of preferred drugs to non-preferred drugs services you receive. Your primary care physician
based on a tiered copayment schedule. In a flexible provides your routine medical care and refers you
formulary, brand-name prescription drugs may be to a specialist if necessary.
assigned to different copayment levels based on
value to the plan and clinical judgment. In some Medicare: A federal health insurance program
cases, drugs may be excluded from coverage under that covers certain people age 65 or older,
a flexible formulary if a therapeutic equivalent is disabled persons under 65 and those who have
covered or available as an over-the-counter drug. end-stage renal disease (permanent kidney failure).
Medicare is directed by the federal Centers
Health Benefits Administrator (HBA): An individual for Medicare & Medicaid Services (CMS), and
responsible for providing benefits assistance to enrollment in Medicare is administered by the
active State employees. HBAs work with the Social Security Administration.
Employee Benefits Division in the Department of
Civil Service to process transactions and answer
questions regarding eligibility and enrollment. You
are responsible for notifying your HBA of changes
that affect your enrollment and/or your or your
dependents eligibility for benefits.

Medicare Advantage Plan: A Medicare option New York State Health Insurance Program
wherein the plan agrees with Medicare to accept a (NYSHIP): NYSHIP covers more than 1.2 million
fixed monthly payment for each Medicare enrollee. public employees, retirees and dependents. It is
In exchange, the plan provides or pays for all one of the largest group health insurance programs
medical care needed by the enrollee. If you join a in the country. The Program provides health care
Medicare Advantage Plan, you replace your original benefits through The Empire Plan and NYSHIP-
(fee-for-service) Medicare coverage (Parts A and B) approved HMOs.
with benefits offered by the plan and all of your
medical care (except for emergency or out-of-area, Option: A health insurance plan offered through
urgently needed care) must be provided, arranged NYSHIP. Options include The Empire Plan and
or authorized by the Medicare Advantage Plan. NYSHIP-approved HMOs within specific geographic
All NYSHIP Medicare Advantage HMOs include areas. The Opt-out Program (NYSHIP code #700)
Medicare Part D drug coverage. The benefits under is also considered a NYSHIP option.
these plans are set in accordance with federal
guidelines for Medicare Advantage Plans. Primary/Medicare primary: A health insurance
plan is primary when it is responsible for paying
Network: A group of doctors, hospitals and/or other health benefits claims before any other group
health care providers who participate in a health health insurance plan. It is important to understand
plan and agree to follow the plans procedures. when Medicare will become primary to your
NYSHIP coverage. Read plan documents for
complete information.
NYSHIPS YOUNG ADULT OPTION

During the Option Transfer Period, eligible adult children of NYSHIP enrollees can enroll in the Young
Adult Option and current Young Adult Option enrollees are able to switch plans. This option allows
unmarried, young adult children up to age 30 to purchase their own NYSHIP coverage. The premium
is the full cost of Individual coverage for the option selected.
Young Adult Option Web Site

For more information about the Young Adult Option, go to www.cs.ny.gov/yao and choose your group.
This site is your best resource for information on NYSHIPs Young Adult Option. If you have additional
questions, please contact the Employee Benefits Division at 518-457-5754 or 1-800-833-4344.

Medicare & NYSHIP
If you are an active employee, NYSHIP (The Empire Medicare Part D is the prescription drug benefit
Plan or a NYSHIP HMO) provides primary coverage for Medicare-primary persons. Medicare-primary
for you and your dependents, regardless of age or Empire Plan enrollees and dependents are enrolled
disability. Exceptions: Medicare is primary for domestic automatically in Empire Plan Medicare Rx, a Part D
partners age 65 or older or for an active employee or prescription drug program. NYSHIP Medicare
dependent of an active employee with end-stage renal Advantage HMOs also provide Medicare Part D
disease (following a 30-month coordination period). prescription drug coverage. You can be enrolled
NYSHIP requires you and your dependents to be in only one Medicare product at a time. Enrolling
enrolled in Medicare Parts A and B when first eligible in a Medicare Part D plan or Medicare Advantage
for Medicare coverage that pays primary to NYSHIP. Plan separate from your NYSHIP coverage may
drastically reduce your benefits overall. For example:
If you are planning to retire and you or your spouse
is 65 or older, contact your Social Security office If you are a Medicare-primary Empire Plan
three months before active employment ends to enrollee or dependent and get your prescription
enroll in Medicare Parts A and B. Medicare becomes drug coverage through Empire Plan Medicare Rx
primary to your NYSHIP coverage the first day of the and then you enroll in another Medicare Part D
month following a runout period of 28 days after plan outside of NYSHIP, the Centers for Medicare
the end of the payroll period in which you retire.* & Medicaid Services (CMS) will terminate your
coverage in Empire Plan Medicare Rx. Because
If you or a dependent is eligible for Medicare you must be enrolled in Empire Plan Medicare Rx
coverage primary to NYSHIP and you dont enroll to maintain Empire Plan coverage, in most cases,
in Parts A and B, The Empire Plan or HMO will not you and your covered dependents will lose all
provide benefits for services Medicare would have coverage under The Empire Plan.
paid if you or your dependent had enrolled.**
If you are enrolled in a NYSHIPMedicare
If you are planning to retire or vest in 2017, learn how Advantage HMO and then enroll in a Medicare
primary Medicare coverage will affect NYSHIP: Part D plan outside of NYSHIP, CMS will terminate
If you are enrolled in original Medicare (Parts A your enrollment in the HMO.
and B) and The Empire Plan: Because Medicare If you have been approved for Extra Help by Medicare
does not provide coverage outside the United and you are enrolled in The Empire Plan or a NYSHIP
States, The Empire Plan pays primary for covered Medicare Advantage HMO, you may be reimbursed for
services received outside the United States. some or all of your cost for Medicare Part D coverage.
If you enroll in a NYSHIP HMO Medicare For information about qualifying for Extra Help, contact
Advantage Plan: You replace your original Medicare. If you have been approved for Extra Help,
Medicare coverage with benefits offered by the contact the Employee Benefits Division or your HMO.
Medicare Advantage Plan. Benefits and networks If you receive prescription drug coverage through a
under the HMOs Medicare Advantage Plan may union Employee Benefit Fund, contact the fund for
differ from your coverage as an active employee. information about Medicare Part D.
To qualify for benefits, you must follow plan rules.
For more information about NYSHIP and Medicare,
If you enroll in a NYSHIPHMOthat coordinates see your NYSHIP General Information Book or ask
coverage with Medicare: You receive the same your HBA for a copy of 2017 Choices for Retirees,
benefits from the HMO as an active employee and Planning for Retirement or Medicare & NYSHIP.
still qualify for original Medicare benefits if you
receive services not covered through your HMO.
* If you are an employee of a PE, you may have a different runout period. Verify with your HBA.
** If you are asked to pay a Part A premium, see your HBA for more information.

Benefits Provided by All Plans
inpatient medical/surgical speech therapy hospice benefits

hospital care prosthetics and durable (at least 210 days)
outpatient medical/surgical medical equipment home health care in lieu of
hospital services orthotic devices hospitalization
physician services medically necessary prescription drug coverage
emergency services* bone density tests including injectable and
laboratory services mammography self-injectable medications,
radiology services inpatient mental health services contraceptive drugs and
devices and fertility drugs
chemotherapy outpatient mental health services
(unless you have coverage
radiation therapy alcohol and substance abuse
through a union Employee
dialysis detoxification
Benefit Fund)
diagnostic services inpatient alcohol rehabilitation
enteral formulas covered
diabetic supplies inpatient drug rehabilitation through either HCAP for The
maternity, prenatal care outpatient alcohol and Empire Plan or the NYSHIP
well-child care drug rehabilitation HMOs prescription drug
chiropractic services family planning and program (unless you have
skilled nursing facility services certain infertility services coverage through a union
(call The Empire Plan program Employee Benefit Fund)
physical therapy
administrators or NYSHIP HMOs second opinion for
occupational therapy
for details) cancer diagnosis
out-of-area emergencies
Please 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.
* Some plans may exclude coverage for airborne ambulance services. Call The Empire Plan or your NYSHIP HMO for details.

The Empire Plan or a NYSHIP HMO
Whats New? The Empire Plan provides:

THE EMPIRE PLAN Network and non-network inpatient and
For 2017, the maximum out-of-pocket limit for outpatient hospital coverage for medical, surgical
covered, in-network services under The Empire and maternity care.
Plan will be $7,150 for Individual coverage and Medical and surgical coverage under the
$14,300 for Family coverage, split between the Participating Provider Program or the Basic Medical
Hospital, Medical/Surgical, Mental Health and Program and Basic Medical Provider Discount
Substance Abuse and Prescription Drug Programs. Program if you choose a nonparticipating provider.
See table below for more information about Home care services, durable medical equipment
how out-of-pocket limits apply to each Empire and certain medical supplies (including diabetic
Plan program. and ostomy supplies), enteral formulas and
diabetic shoes through the Home Care Advocacy
The Empire Plan Program (HCAP).
The Empire Plan is a unique plan designed exclusively Chiropractic treatment and physical therapy
for New York States public employees. The Empire coverage through the Managed Physical
Plan has many managed care features, but enrollees Medicine Program.
are not required to choose a primary care physician Inpatient and outpatient mental health and
and do not need referrals to see specialists. However, substance abuse coverage.
certain services, such as hospital and skilled nursing Prescription drug coverage, unless it is provided
facility admissions, certain outpatient radiological by a union Employee Benefit Fund.
tests, certain mental health and substance abuse Center of Excellence Programs for cancer,
treatment/services, home care and some prescription transplants and infertility.
drugs, require preapproval. 24-hour Empire Plan NurseLineSM for health
The New York State Department of Civil Service information and support.
contracts with qualified companies to administer Worldwide coverage.
the Plan. The Empire Plan is self insured.
2017 Empire Plan Maximum Out-of-Pocket Limits for In-Network Services

Coverage Type Prescription Hospital, Medical/Surgical Total
Drug Program* and Mental Health
and Substance Abuse
Programs, Combined
Individual Coverage $2,500 $4,650 $7,150
Family Coverage $5,000 $9,300 $14,300
* Does not apply to Medicare-primary enrollees or the dependents of Medicare-primary enrollees.

PROVIDERS NYSHIP Health
Under The Empire Plan, you can choose from more Maintenance Organizations
than 250,000 participating physicians and other A health maintenance organization (HMO) is a
providers and facilities nationwide and from more managed care system in a specific geographic area
than 68,000 participating pharmacies across the that provides comprehensive health care coverage
United States or a mail service pharmacy. through a network of providers.
Some licensed nurse practitioners and convenience Coverage for services received outside the
care clinics participate with The Empire Plan. Be specified geographic area is limited. HMO
sure to confirm participation before receiving care. enrollees who use doctors, hospitals or
pharmacies outside the HMOs network must,
Under the Guaranteed Access benefit, The Empire
in most cases, pay the full cost for services
Plan provides access to network benefits for covered
unless authorized by the HMO or in the case
services provided by primary care physicians and
of an emergency.
certain specialists when you do not have access to
a network provider in New York State and specific Enrollees usually choose a primary care physician
counties in Connecticut, Massachusetts, New Jersey, (PCP) from the HMOs network for routine medical
Pennsylvania and Vermont that share a border with care and for referrals to specialists and hospitals
New York State. Note: This benefit does not apply to when medically necessary.
enrollees of PEs. HMO enrollees usually pay a copayment as a
per-visit fee or coinsurance (percentage of cost).
HMOs have no annual deductible.
Referrals to network specialists may be required.
Claim forms rarely are required.
All NYSHIP HMOs provide a wide range of health
services. Each offers a specific package of hospital,
medical, surgical and preventive care benefits.
These services are provided or arranged by the PCP
selected by the enrollee from the HMOs network.
CONSIDER COST
When considering cost, think about all your costs throughout the year, not just your biweekly paycheck
deduction. Keep in mind any out-of-pocket expenses you are likely to incur during the year, such as
copayments for prescriptions and other services, coinsurance and any costs of using providers or
services not covered under the plan. Watch for the NYSHIP Rates & Deadlines for 2017 flyer that will be
mailed to your home and posted on our web site, www.cs.ny.gov/employee-benefits, as soon as rates
are approved. (Note: PEs will provide premium information to their employees). Along with this booklet,
which provides copayment information, NYSHIP Rates & Deadlines for 2017 will provide the information
you need to determine your annual cost under each of the available plans.

The Empire Plan or a NYSHIP HMO
All NYSHIP HMOs cover inpatient and outpatient

NYSHIP HMOS AND MEDICARE
hospital care at a network hospital and prescription
drug coverage.* If you are Medicare primary, see page 6 for an
explanation of how Medicare affects your NYSHIP
NYSHIPHMOs are organized in one of two ways: HMO coverage.
A network HMO provides medical services
through its own health centers, as well as outside Summary of Benefits and Coverage
participating physicians, medical groups and The Summary of Benefits and Coverage (SBC) is a
multispecialty medical centers. standardized comparison document required by the
An independent practice association (IPA) HMO Patient Protection and Affordable Care Act (PPACA).
provides medical services through private To view a copy of an SBC for The Empire Plan or a
practice physicians who have contracted NYSHIP HMO, visit www.cs.ny.gov/sbc/index.cfm. If
independently with the HMO to provide services you do not have internet access, call 1-877-7-NYSHIP
in their offices. (1-877-769-7447) and select the Medical Program
A member enrolling in a network or IPA model HMO to request a copy of the SBC for The Empire Plan.
may be able to select a doctor he or she already If you need an SBC for a NYSHIP HMO, contact
uses if that doctor participates with the HMO. the HMO.
See the individual HMO pages in this booklet for
additional benefit information and to learn which
HMOs serve your geographic area.
* For PE employees: Unless prescription drug coverage is provided through a union Employee Benefit Fund.

Making a Choice
Selecting a health insurance plan is an important How to Use the Choices

and personal decision. Only you know your familys Benefit Charts, Pages 18 43
lifestyle, health, budget and benefit preferences.
The Empire Plan and NYSHIP HMOs are summarized
Think about what health care you and your covered
in this booklet. The Empire Plan is available to all
dependents might need during the next year.
employees. You may choose an available NYSHIP
Review the plans, and ask for more information.
HMO based on the area in which you live or work.
Here are several questions to consider:
Identify the plans that best serve your needs, and
What is my premium for the health plan? call each plan for details before you choose.
What benefits does the plan have for office visits and
All NYSHIP plans must include a minimum level of
other medical care? What is my share of the cost?
benefits (see page 7). For example, The Empire Plan
What benefits does the plan have for prescription and all NYSHIP HMOs provide a paid-in-full benefit
drugs? Will the medicine I take be covered under for medically necessary inpatient hospital care at
the plan? What is my share of the cost? What type network hospitals.
of formulary does the plan have? Am I required to
use the mail service pharmacy? (If you receive Use the charts to compare plans. The charts list out-
your drug coverage from a union Employee of-pocket expenses and benefit limitations effective
Benefit Fund, ask the fund about your benefits.) January 1, 2017. See plan documents for complete
information on benefit limitations.
Does the plan cover special needs? How is durable
medical equipment and other supplies covered? To generate a side-by-side comparison of the
Are there any benefit limitations? (If you or one of benefits provided by each of the NYSHIP plans in
your dependents has a medical or mental health/ your area, use the NYSHIP Plan Comparison tool,
substance abuse condition requiring specific available on NYSHIP Online. Go to our homepage
treatment or other special needs, check on coverage at www.cs.ny.gov/employee-benefits. Select your
carefully. Do not assume you will have coverage. group and plan, if prompted, and then choose
Ask The Empire Plan program administrators or Health Benefits & Option Transfer. Click on Rates
HMOs about your specific treatment.) and Health Plan Choices and then NYSHIP Plan
Are routine office visits and urgent care covered Comparison. Select your group and the counties
for out-of-area college students, or is only in which you live and work. Then, check the box
emergency health care covered? next to the plans you want to compare and click on
What benefits are available for a catastrophic Compare Plans to generate the comparison table.
illness or injury? Note: Most benefits described in this booklet are
What choice of providers do I have under the subject to medical necessity and may involve
plan? (Ask if the provider or facilities you use limitations or exclusions. Please refer to plan
are covered.) How would I consult a specialist documents or call the plans directly for details.
if I needed one? Would I need a referral?
How much paperwork is involved in the health
If You Decide to Change Your Plan
plan? Do I have to fill out forms? If you have reviewed the coverage and cost of
your options and decide to change your plan, submit
Things to Remember a completed Health Insurance Transaction Form
Gather as much information as possible. (PS-404) or change your option online using
Consider your and your familys unique needs. MyNYSHIP (if you are an active employee of a New
Compare the coverage and cost of your options. York State agency) before the Option Transfer deadline
Look for a health plan that provides the best announced in the rate flyer. Note: MyNYSHIP cannot
balance of cost and benefits for you. be used to elect the Opt-out Program (see page 15).

The Empire Plan and NYSHIP
Will I be covered for medically necessary care I receive away from home?
The Empire Plan:
Yes. The Empire Plan provides worldwide coverage. However, access to network benefits is
not guaranteed in all states and regions.
NYSHIP HMOs:
Under an HMO, you are always covered for emergency care. Some HMOs may provide coverage
for routine care outside the HMO service area. Some HMOs provide coverage for college students
away from home if the care is urgent or if follow-up care has been preauthorized. See the out-of-
area benefit description on each HMO page for more information, or contact the HMO directly.
If I am diagnosed with a serious illness, can I see a physician or go to a

hospital that specializes in my illness?
The Empire Plan:
Yes. You can use the specialist of your choice. If the doctor you choose participates in The Empire
Plan network, benefits will apply for covered services. You have Basic Medical Program benefits
for nonparticipating providers and Basic Medical Provider Discount Program benefits for
nonparticipating providers who are part of the Empire Plan MultiPlan group (see page 21 for more
information on the Basic Medical Provider Discount Program). Your hospital benefits will differ
depending on whether you choose a network or non-network hospital (see page 13 for details).
NYSHIP HMOs:
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?
The Empire Plan:
Your copayment should be your only expense if you receive medically necessary and covered
services and you use a participating provider.
NYSHIP HMOs:
As long as you receive medically necessary and covered services, follow HMO requirements
and receive the appropriate referral (if required), your copayment or coinsurance should be your
only expense.

HMOs: Similarities and Differences
Can I use the hospital of my choice?

The Empire Plan:
Yes. You have coverage worldwide, but your benefits differ depending on whether you choose a
network or non-network hospital. Your benefits are highest at network hospitals participating in
the BlueCross and BlueShield Association BlueCard PPO Program or for mental health or
substance abuse care in the Beacon Health Options network.
Network hospital inpatient: Paid-in-full hospitalization benefits.
Network hospital outpatient and emergency care: Subject to network copayments.
Non-network hospital inpatient stays and outpatient services: 10 percent coinsurance for inpatient
stays and the greater of 10 percent coinsurance or $75 for outpatient services, up to the combined
annual coinsurance maximum per enrollee, per enrolled spouse or domestic partner and per all
enrolled dependent children combined (see page 20).
NYSHIP HMOs:
Except in an emergency, you generally do not have coverage at non-network hospitals unless
authorized by the HMO.
What kind of care is available for physical therapy and chiropractic care?
The Empire Plan:
You have guaranteed access to unlimited medically necessary care when you follow Plan requirements.
NYSHIP HMOs:
Coverage is available for a specified number of days/visits each year, as long as you follow the
HMOs requirements.
What if I need durable medical equipment, medical supplies or home nursing?

The Empire Plan:
You have guaranteed, paid-in-full access to medically necessary home care, equipment and supplies1
through the Home Care Advocacy Program (HCAP) when preauthorized and arranged by the Plan.
NYSHIP HMOs:
Benefits are available and vary depending on the HMO. Benefits may require a greater percentage
of cost sharing.
1 Diabeticshoes have an annual maximum benefit of $500.

Note: T
hese responses are generic and highlight only general differences between The Empire Plan and NYSHIP HMOs.
Details for each plan are available on individual plan pages beginning on page 18 of this booklet, in the Empire
Plan Certificate (available online or from your HBA) and in the HMO contracts (available from each HMO).

Questions & Answers
Q: Can I join The Empire Plan or any authorization to have the providers services
NYSHIP-approved HMO? covered. In most circumstances, HMOs do not
A: The Empire Plan is available worldwide. To provide benefits for services by nonparticipating
enroll or continue enrollment in a NYSHIP- providers or hospitals. Under The Empire Plan,
approved HMO, you must live or work in that you have benefits for participating and
HMOs service area. If you move permanently nonparticipating providers.
out of and/or no longer work in your HMOs Note: You cannot change your plan outside the
service area, you must change options. See Option Transfer Period if your only reason for the
Plans by County on pages 16 and 17 and the change is that your provider no longer participates.
individual HMO pages in this booklet to check
the counties each HMOwill serve in 2017. Q: I have a preexisting condition. Will I have
coverage if I change options?
Q: How do I find out which providers and
A: Yes. Under NYSHIP, you can change your option
hospitals participate? What if my doctor or
and still have coverage for a preexisting condition.
other provider leaves my plan?
There are no preexisting condition exclusions
A: Check with your providers directly to see in any NYSHIP plan. However, coverage and
whether they participate in The Empire Plan exclusions differ. Ask the plan you are considering
or in a NYSHIP HMO. about coverage for your condition.
For Empire Plan provider information: Q: What if I retire in 2017 and become eligible
Use the online provider directories at for Medicare?
www.cs.ny.gov/employee-benefits. Select A: Regardless of which option you choose, as
your group if prompted, and then click on Find a retiree, you and your dependent must be
a Provider. Note: This is the most up-to-date enrolled in Medicare Parts A and B when either
source for provider information. of you first becomes eligible for primary Medicare
Ask your HBA for The Empire Plan Participating coverage (see page 6). Please note that your
Provider Directory. (Always check with a NYSHIP benefits become secondary to Medicare
provider to ensure current participation.) and that your benefits may change.
Call The Empire Plan toll free at Q: I am a COBRA dependent in a Family plan.
1-877-7-NYSHIP (1-877-769-7447) and select Can I switch to Individual coverage and select a
the appropriate program for the type of different health plan than the rest of my family?
provider you need.
A: Yes. As a COBRA dependent, you may elect to
For HMO provider information: change to Individual coverage in a plan different
Visit the web sites (web site addresses are from the enrollees Family coverage. During the
provided on the individual HMO pages in Option Transfer Period, you may enroll in The
this booklet). Empire Plan or choose any NYSHIP-approved
HMO in the area where you live or work.
Call the telephone numbers on the HMO
pages in this booklet. Ask which providers Q: I elected the Opt-out Program in 2016. Can I
participate and which hospitals are affiliated. switch to NYSHIP health coverage for 2017?
If you choose a provider who does not A: Yes. All options are available during the Option
participate in your plan, check carefully whether Transfer Period (see Making a Choice, page 11).
benefits will be available to you. Ask if you need However, if you decide to stay in the Opt-out
Program, you must reenroll for 2017.

The Opt-Out Program NYSHIP Code #700
An Opt-out Program is available to eligible NYSHIP option, an individual cannot opt out
employees who have other employer-sponsored through one employer and be enrolled in NYSHIP
group health benefits. If eligible, you may opt out health benefits in his or her own right through
of NYSHIP coverage in exchange for an incentive another employer.
payment. Note: The State Opt-out Program is not If the employee is covered as a dependent on
available to employees of PEs; however, a PE may another NYSHIP policy through a local government
offer a similar option. or public entity, he or she is only eligible for the
The annual incentive payment is $1,000 for opting Individual Opt-out incentive amount ($1,000).
out of Individual coverage or $3,000 for opting Make sure the other employer-sponsored plan
out of Family coverage. The incentive payment is will permit you to enroll as a dependent. You are
prorated and credited in your biweekly paycheck responsible for making sure your other coverage is
throughout the year (payable only when an in effect during the period you opt out of NYSHIP.
employee is eligible for NYSHIP coverage at the
employee share of the premium). Note: Opt-out Note: Opt-out Program participation satisfies
incentive payments increase your taxable income. NYSHIP enrollment requirements at the time
of your retirement. The Opt-out Program is not
Enrollment in the Opt-out Program does not available to retirees.
continue automatically from year to year. To be
eligible for the incentive payments, you must enroll Electing To Opt Out
during each Option Transfer Period and attest to If you are currently enrolled in NYSHIP and wish to
having other coverage for the coming plan year. participate in the Opt-out Program, you must elect
to opt out during the annual Option Transfer Period
Eligibility Requirements
and attest to and provide information regarding
To be eligible for the Opt-out Program, you must: your other employer-sponsored group health
be a member of a group eligible for the benefits for the next plan year.
Opt-out Program, To elect the Opt-out Program, you must submit
have been enrolled in the Opt-out Program for the a completed and signed NYS Health Insurance
prior plan year or enrolled in a NYSHIP health plan Transaction Form (PS-404) and an Opt-out
by April 1, 2016, (or on your first date of NYSHIP Attestation Form (PS-409). Your NYSHIP coverage
eligibility if that date is later than April 1) and will terminate at the end of the plan year, and the
remain continuously enrolled while eligible for the incentive payments will begin with the first pay
employee share of the premium through the end period affecting coverage for 2017.
of 2016.
Once enrolled in the Opt-out Program, you are not
To qualify for the Opt-out Program, you must be eligible for the incentive payment during any period
covered under an employer-sponsored group that you do not meet the requirements for the State
health insurance plan through other employment contribution to the cost of your NYSHIP coverage.
of your own or a plan that your spouse, domestic Additionally, if you are receiving the opt-out incentive
partner or parent has as the result of his or her for Family coverage and your last dependent loses
employment. New York State employees cannot opt NYSHIP eligibility, you will only be eligible for the
out of NYSHIP if they are covered under NYSHIP as Individual payment from that date forward.
a dependent through another NYS employee.
Reminder: All options are available to you during the
According to NYSHIP rules, an individual cannot be Option Transfer Period. If you are currently enrolled
enrolled in two NYSHIP options in his or her own in the Opt-out Program, you may choose other
right. Since the Opt-out Program is considered a NYSHIP coverage or elect to opt out again for 2017.

Plans by County
The Empire Plan

The 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 18-27
for a summary of The Empire Plan.
Page in Choices 18 28 30 32 32 32 34 34 34 36 36 36 38 38 40 42 42 42 42 42
of Western New York*
059 Independent Health*

BlueCross BlueShield
Empire BlueCross
Empire BlueCross
Empire BlueCross
BlueShield HMO*
BlueShield HMO*
BlueShield HMO*
The Empire Plan
066 Blue Choice*
072 HMOBlue
HMOBlue
063 CDPHP*
300 CDPHP*
CDPHP*
058 MVP*
060 MVP*
330 MVP*
340 MVP*
360 MVP
050 HIP*
220 HIP
350 HIP
290
280
320
067
NYSHIP Code
001
160
310
Albany
Allegany
Bronx
Broome
Cattaraugus
Cayuga
Chautauqua
Chemung
Chenango
Clinton
Columbia
Cortland
Delaware
Dutchess
Erie
Essex
Franklin
Fulton
Genesee
Greene
Hamilton
Herkimer
Jefferson
Kings
Lewis
Livingston
Madison
Monroe
Montgomery
Nassau
New York
* Medicare-primary NYSHIP enrollees will be enrolled in this HMOs Medicare Advantage Plan. For more information
about NYSHIP Medicare Advantage Plans, ask your HBA for a copy of 2017 Choices for Retirees.
Health Maintenance Organizations (HMOs)
Most NYSHIP enrollees have a choice among HMOs. You may enroll or continue to be enrolled in any NYSHIP-
approved HMO that serves the area where you live or work. You may not be enrolled in an HMO outside your
area. This list will help you determine which HMOs are available by county. The pages indicated describe
benefits available from each HMO.
Page in Choices 18 28 30 32 32 32 34 34 34 36 36 36 38 38 40 42 42 42 42 42
of Western New York*
059 Independent Health*

BlueCross BlueShield
Empire BlueCross
Empire BlueCross
Empire BlueCross
BlueShield HMO*
BlueShield HMO*
BlueShield HMO*
The Empire Plan
066 Blue Choice*
072 HMOBlue
HMOBlue
063 CDPHP*
300 CDPHP*
CDPHP*
058 MVP*
060 MVP*
330 MVP*
340 MVP*
360 MVP
050 HIP*
220 HIP
350 HIP
290
280
320
067
001
160
310
NYSHIP Code
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
* Medicare-primary NYSHIP enrollees will be enrolled in this HMOs Medicare Advantage Plan. For more information
about NYSHIP Medicare Advantage Plans, ask your HBA for a copy of 2017 Choices for Retirees.
The Empire Plan NYSHIP Code #001
This section summarizes benefits available under medically necessary. Guaranteed access to network
each portion of The Empire Plan as of January 1, 2017.1 benefits nationwide. Non-network benefits available.
You may also visit www.cs.ny.gov/employee-benefits Under the Benefits Management Program, you must
or call toll free 1-877-7-NYSHIP (1-877-769-7447) to call the Medical/Surgical Program for Prospective
connect to: Procedure Review before an elective (scheduled)
magnetic resonance imaging (MRI), magnetic
Medical/Surgical Program
resonance angiography (MRA), computerized
UnitedHealthcare tomography (CT), positron emission tomography (PET)
Medical and surgical coverage through: scan or nuclear medicine test, unless you are having
Participating Provider Program More than the test as an inpatient in a hospital (see the Empire
250,000 physicians and other providers participate; Plan Certificate for details).
certain services are subject to a $20 copayment. When arranged by the Medical/Surgical Program, a
Basic Medical Program If you use a voluntary, paid-in-full specialist consultant evaluation
nonparticipating provider, the Program considers is available. Voluntary outpatient medical case
up to 80 percent of usual and customary charges management is available to help coordinate
for covered services after the combined annual services for catastrophic and complex cases.
deductible is met. After the combined annual
coinsurance maximum is met, the Plan pays up Hospital Program
to 100 percent of usual and customary charges Empire BlueCross BlueShield
for covered services. See Cost Sharing (beginning The following benefit level applies for covered
on page 20) for additional information. services received at a BlueCross and BlueShield
Basic Medical Provider Discount Program If you Association BlueCard PPO network hospital:
are Empire Plan primary and use a nonparticipating
Hospital inpatient stays are covered at no cost
provider who is part of the Empire Plan MultiPlan
to you.
group, your out-of-pocket costs may be lower
Hospital outpatient and emergency care are
(see page 21).
subject to network copayments.
Home Care Advocacy Program (HCAP) Paid-in-full When you use a network hospital, anesthesiology,
benefits for home care, durable medical equipment pathology and radiology provider charges for
and certain medical supplies (including diabetic and covered hospital services are paid in full under
ostomy supplies), enteral formulas and diabetic the Medical/Surgical Program (if The Empire Plan
shoes. (Diabetic shoes have an annual maximum provides your primary coverage).
benefit of $500.) Guaranteed access to network
Certain covered outpatient hospital services
benefits nationwide. Limited non-network benefits
provided at network hospital extension clinics
available (see the Empire Plan Certificate/Reports
are subject to hospital outpatient and emergency
for details).
care copayments.
Managed Physical Medicine Program Chiropractic Except as noted above, physician charges
treatment and physical therapy through a Managed received in a hospital setting will be paid in full if
Physical Network (MPN) provider are subject to a the provider is a participating provider under the
$20 copayment. Unlimited network benefits when Medical/Surgical Program. Physician charges for
1 These benefits are subject to medical necessity and to limitations and exclusions described in the Empire Plan
Certificate and Empire Plan Reports/Certificate Amendments.

covered services received from a non-network all charges for any days care determined not to
provider will be paid in accordance with the Basic be medically necessary.
Medical portion of the Medical/Surgical Program. Voluntary inpatient medical case management is
The following benefit level applies for hospital available to help coordinate services for
services received at non-network hospitals (for catastrophic and complex cases.
Empire Plan-primary enrollees only 2):
Mental Health and
Non-network hospital inpatient stays and
outpatient services: 10 percent coinsurance for
Substance Abuse Program
inpatient stays and the greater of 10 percent Beacon Health Options Inc.
coinsurance or $75 for outpatient services per The Mental Health and Substance Abuse (MHSA)
visit, up to the combined annual coinsurance Program offers two levels of benefits. If you call the
maximum per enrollee, per enrolled spouse or MHSA Program before you receive services and
domestic partner, per all enrolled dependent follow their recommendations, you receive:
children combined (see page 20).
The Empire Plan will approve network benefits for NETWORK BENEFITS
hospital services received at a non-network facility if: (unlimited when medically necessary)
Your hospital care is emergency or urgent. inpatient (paid in full)
No network facility can provide the medically crisis intervention (up to three visits per crisis paid
necessary services. in full; after the third visit, the $20 copayment per
You do not have access to a network facility visit applies)
within 30 miles of your residence. outpatient including office visits, home-based or
Another insurer or Medicare provides your telephone counseling and nurse practitioner
primary coverage (pays first). services ($20 copayment)
outpatient rehabilitation with an approved
PREADMISSION CERTIFICATION REQUIREMENTS structured outpatient rehabilitation program for
Under the Benefits Management Program, if substance abuse ($20 copayment)
The Empire Plan is your primary coverage, you If you do NOT follow the requirements for network
must call the Hospital Program for certification coverage, you receive:
of any inpatient stay:
before a maternity or scheduled (nonemergency) NON-NETWORK BENEFITS3
hospital admission (unlimited when medically necessary)
within 48 hours or as soon as reasonably possible For Practitioner Services: the MHSA Program will
after an emergency or urgent hospital admission consider up to 80 percent of usual and customary
before admission or transfer to a skilled charges for covered outpatient practitioner
nursing facility services after you meet the combined annual
If you do not follow the preadmission certification deductible per enrollee, per enrolled spouse
requirement for the Hospital Program, you must pay: or domestic partner, per all enrolled dependent
a $200 hospital penalty if it is determined any children combined. After the combined annual
portion was medically necessary and coinsurance maximum is reached per enrollee,
2 IfMedicare or another plan provides primary coverage, you receive network benefits for covered services at both
network and non-network hospitals.
3 You are responsible for ensuring that MHSA Program certification is received for care obtained from a non-network
practitioner or facility.

per enrolled spouse or domestic partner, per all coverage for Hospital, Medical/Surgical and
enrolled dependent children combined, the Plan MHSA Programs, combined. Once you reach the
pays up to 100 percent of usual and customary limit, you will have no additional copayments.
charges for covered services (see page 20). If you use a nonparticipating provider or non-
For Approved Facility Services: You are responsible network facility, benefits for covered services
for 10 percent of covered billed charges up to the are subject to a deductible and/or coinsurance.
combined annual coinsurance maximum per
enrollee, per enrolled spouse or domestic partner, COMBINED ANNUAL DEDUCTIBLE
per all enrolled dependent children combined. After For medical/surgical and mental health and
the coinsurance maximum is met, the Plan pays substance abuse services, The Empire Plan has a
100 percent of billed charges for covered services combined annual deductible of $1,000 per enrollee,
(see page 20). $1,000 per enrolled spouse/domestic partner and
Outpatient treatment sessions for family members $1,000 per all dependent children combined. The
of an alcoholic, alcohol abuser or substance combined annual deductible must be met before
abuser are covered for a maximum of 20 visits covered services under the Basic Medical Program
per year for all family members combined. and non-network expenses under both the HCAP
Empire Plan Cost Sharing and MHSA Programs can be reimbursed. The
Managed Physical Medicine Program has a
PLAN PROVIDERS separate $250 deductible per enrollee, $250 per
Under The Empire Plan, benefits are available for enrolled spouse/domestic partner and $250 per all
covered services when you use a participating or dependent children combined that is not included
nonparticipating provider. However, your share of in the combined annual deductible.
the cost of covered services depends on whether
The $1,000 combined annual deductible amount
the provider you use participates with the Plan.
will be reduced to $500 per calendar year for
If you use an Empire Plan participating or network employees in or equated to Salary Grade 6 or
provider or facility, you pay a copayment for certain below on January 1, 2017. Note: This reduction is
services. Some services are covered at no cost to not available to judges and justices or employees
you. The provider or facility files the claim and is of PEs.
reimbursed by The Empire Plan.
After you satisfy the combined annual deductible,
You are guaranteed access to network benefits The Empire Plan pays 80 percent of the usual and
for certain services when you contact the program customary charge for the Basic Medical Program
before receiving services and follow program and non-network practitioner services for the MHSA
requirements for: Program, 50 percent of the network allowance for
MHSA Program services covered services for non-network HCAP services
Managed Physical Medicine Program services and 90 percent of the billed charges for covered
(physical therapy and chiropractic care) services for non-network approved facility services
Home Care Advocacy Program (HCAP) services for the MHSA Program. You are responsible for the
(including durable medical equipment) remaining 20 percent coinsurance and all charges in
excess of the usual and customary charge for Basic
2017 ANNUAL MAXIMUM OUT-OF-POCKET LIMIT Medical Program and non-network practitioner
Your maximum out-of-pocket expenses for services and 10 percent for non-network MHSA-
in-network covered services will be $4,650 approved facility services. There is no coinsurance
for Individual coverage and $9,300 for Family maximum for HCAP or Managed Physical Medicine
Program services.

COMBINED ANNUAL COINSURANCE MAXIMUM
The Empire Plan has a combined annual THE EMPIRE PLAN CENTER
coinsurance maximum of $3,000 per enrollee, OF EXCELLENCE PROGRAMS
$3,000 per enrolled spouse/domestic partner The Center of Excellence for Cancer Program
and $3,000 per all dependent children combined. includes paid-in-full coverage for cancer-related
After you reach the combined annual coinsurance expenses received through Cancer Resource
maximum, you will be reimbursed up to 100 percent Services (CRS). CRS is a nationwide network
of the usual and customary charges. You are that includes many of the nations leading
responsible for paying the provider and will be cancer centers. The enhanced benefits,
reimbursed by the Plan for covered charges. You including a travel allowance, are available
are also responsible for paying all charges in only when you are enrolled in the Program.
excess of the usual and customary charge. The Center of Excellence for Transplants
The $3,000 combined annual coinsurance maximum Program provides paid-in-full coverage for
will be reduced to $1,500 per calendar year for services covered under the Program and
employees in or equated to Salary Grade 6 or below. performed at a qualified Center of Excellence.
Note: This reduction is not available to judges and The enhanced benefits, including a travel
justices or employees of PEs. allowance, are available only when you are
The combined annual coinsurance maximum will enrolled in the Program and The Empire Plan
be shared among the Basic Medical Program and is your primary coverage. Precertification
non-network coverage under the Hospital Program is required.
and MHSA Program. The Managed Physical The Center of Excellence for Infertility
Medicine Program and HCAP do not have a Program is a select group of participating
coinsurance maximum. providers recognized as leaders in
reproductive medical technology and infertility
BASIC MEDICAL PROVIDER DISCOUNT PROGRAM procedures. Benefits are paid in full, subject to
If you are Empire Plan primary, The Empire Plan also the lifetime maximum benefit of $50,000 per
includes a program to reduce your out-of-pocket covered individual. A travel allowance is
costs when you use a nonparticipating provider. available. Precertification is required.
The Empire Plan Basic Medical Provider Discount For details on the Empire Plan Centers
Program offers discounts from certain physicians of Excellence Programs, see the Empire
and providers who are not part of The Empire Plan Plan Certificate/Reports and Reporting On
participating provider network. These providers are Center of Excellence Programs available at
part of the nationwide MultiPlan group, a provider www.cs.ny.gov/employee-benefits or from
organization contracted with UnitedHealthcare. your HBA.
Empire Plan Basic Medical Program provisions apply,
and you must meet the combined annual deductible.
Providers in the Basic Medical Provider Discount the services qualify for the Basic Medical Provider
Program accept a discounted fee for covered Discount Program. Your explanation of benefits,
services. Your 20 percent coinsurance is based on which details claims payments, shows the
the lower of the discounted fee or the usual and discounted amount applied to billed charges.
customary charge. The provider submits your To find a provider in the Empire Plan Basic Medical
claims, and UnitedHealthcare pays The Empire Plan Provider Discount Program, ask if the provider is an
portion of the provider fee directly to the provider if Empire Plan MultiPlan provider or call The Empire

Plan toll free at 1-877-7-NYSHIP (1-877-769-7447), (single-source brand-name drugs/devices) do not

choose the Medical Program and ask a require a copayment. The copayment waivers for
representative for help. You can also visit our web these drugs will only be provided if the drug is
site at www.cs.ny.gov/employee-benefits. Select your filled at a network pharmacy.
group if prompted, and then click on Find a Provider. Certain preventive adult vaccines, when
You receive the maximum plan benefits when you administered at a pharmacy that participates
use participating providers. For more information, in the CVS Caremark National Vaccine Network,
read Reporting On Network Benefits. You can find do not require a copayment.
this publication at www.cs.ny.gov/employee-benefits, For certain maintenance medications, you are
or ask your HBA for a copy. required to fill at least two 30-day supplies using
your Empire Plan Prescription Drug Program
Prescription Drug Program benefits before a supply for greater than
CVS Caremark, Inc. 30 days will be covered. If you attempt to fill a
prescription for a maintenance medication for
The Prescription Drug Program does not apply to
more than a 30-day supply at a network or mail
those who have drug coverage through a union
service pharmacy, the last 180 days of your
Employee Benefit Fund.
prescription history will be reviewed to determine
When you use a network pharmacy, the mail whether at least 60 days worth of the drug was
service pharmacy or the specialty pharmacy for previously dispensed. If not, only a 30-day fill will
up to a 30-day supply of a covered drug, you pay be approved. This program is referred to as the
a $5 copayment for Level 1 or most generic drugs; New to You Program.
a $25 copayment for Level 2, preferred drugs or When you fill a prescription for a covered brand-
compound drugs; and a $45 copayment for Level 3, name drug that has a generic equivalent, you pay
certain generic drugs or non-preferred drugs. the Level 3 or non-preferred copayment, plus the
For a 31- to 90-day supply of a covered drug difference in cost between the brand-name drug
through a network pharmacy, you pay a $10 and the generic equivalent (or ancillary charge),
copayment for Level 1 or most generic drugs; a not to exceed the full retail cost of the drug,
$50 copayment for Level 2, preferred drugs or unless the brand-name drug has been placed
compound drugs; and a $90 copayment for Level 3, on Level 1 of the Flexible Formulary. Exceptions
certain generic drugs or non-preferred drugs. apply. Please contact the Empire Plan Prescription
For a 31- to 90-day supply of a covered drug Drug Program at 1-877-7-NYSHIP (1-877-769-7447)
through the mail service pharmacy or the for more information.
specialty pharmacy, you pay a $5 copayment for The Empire Plan has a flexible formulary that
Level 1 or most generic drugs; a $50 copayment excludes certain prescription drugs from coverage.
for Level 2, preferred drugs or compound drugs; Prior authorization is required for certain drugs.
and a $90 copayment for Level 3, certain generic A pharmacist is available 24 hours a day to
drugs or non-preferred drugs. answer questions about your prescriptions.
Oral chemotherapy drugs for the treatment of You can use a nonparticipating pharmacy or pay
cancer do not require a copayment. cash at a participating pharmacy (instead of using
Tamoxifen and Raloxifene, when prescribed for your Empire Plan Benefit Card) and fill out a claim
the primary prevention of breast cancer, do not form for reimbursement. In almost all cases, you will
require a copayment. In addition, generic oral not be reimbursed the total amount you paid for the
contraceptive drugs and devices or brand-name prescription, and your out-of-pocket expenses may
drugs/devices without a generic equivalent exceed the usual copayment amount. To reduce

your out-of-pocket expenses, use your Empire Plan to request refills or to speak to a specialty-trained
Benefit Card whenever possible. pharmacist or nurse, call The Empire Plan toll free at
1-877-7-NYSHIP (1-877-769-7447) between 7:30 a.m.
2017 ANNUAL MAXIMUM OUT-OF-POCKET LIMIT* and 9 p.m., Monday through Friday, Eastern time.
Your annual maximum out-of-pocket expenses for Choose the Prescription Drug Program, and ask
covered drugs received from a network pharmacy to speak with Specialty Customer Care.
will be $2,500 for Individual coverage and $5,000 Medicare-primary enrollees and dependents: If
for Family coverage. Once you reach the limit, you are or will be Medicare primary in 2017, ask
you will have no additional copayments for your HBA for a copy of 2017 Choices for Retirees
prescription drugs. for information about your coverage under Empire
Plan Medicare Rx, a Medicare Part D prescription
SPECIALTY PHARMACY drug program.
The Prescription Drug Programs Specialty
Pharmacy Program offers enhanced services to
individuals using specialty drugs (such as those The Empire Plan NurselineSM
used to treat complex conditions and those that Call The Empire Plan and press or say 5
require special handling, special administration or for the NurseLineSM for health information
intensive patient monitoring). The complete list of and support.
specialty drugs included in the Specialty Pharmacy Representatives are available 24 hours a day,
Program is available on NYSHIP Online. Go to seven days a week.
www.cs.ny.gov/employee-benefits. Choose your
group, then Using Your Benefits and then Specialty
Pharmacy Drug List. Empire Plan Benefits
The Program provides enrollees with enhanced Are Available Worldwide
services that include disease and drug education; The Empire Plan gives you the freedom to choose a
compliance, side-effect and safety management; participating provider or a nonparticipating provider.
expedited, scheduled delivery of medications at
no additional charge; refill reminder calls; and all Teletypewriter (TTY) Numbers
necessary supplies (such as needles and syringes) For callers who use a TTY device because of a
applicable to the medication. hearing or speech disability. All TTY numbers are
CVS Caremark Specialty Pharmacy is the toll free.
designated pharmacy for the Specialty Pharmacy Medical/Surgical Program
Program. Under the Specialty Pharmacy Program, TTY only:................................................................ 1-888-697-9054
you are covered for an initial 30-day fill of most
Hospital Program
specialty medications at a retail pharmacy, but
TTY only:................................................................. 1-800-241-6894
all subsequent fills must be obtained through
the designated specialty pharmacy. When CVS Mental Health and Substance Abuse Program
Caremark dispenses a specialty medication, the TTY only:.................................................................. 1-855-643-1476
applicable mail service copayment is charged. To Prescription Drug Program

get started with CVS Caremark Specialty Pharmacy, TTY only:.........................................................................................................711
* The annual maximum out-of-pocket limit does not apply to Empire Plan Medicare Rx.

The Empire Plan
For employees of the State of New York, Participating Employers, their enrolled dependents and for COBRA
and Young Adult Option enrollees with their NYSHIP benefits.

Benefits Network Hospital Benefits1,2 Participating Provider2 Nonparticipating Provider
Office Visits2 $20 per visit Basic Medical3
Specialty Office Visits2 $20 per visit Basic Medical3
Diagnostic Services:2
Radiology $304 or $40 per outpatient visit $20 per visit Basic Medical3
Lab Tests $304 or $40 per outpatient visit $20 per visit Basic Medical3
Pathology No copayment $20 per visit Basic Medical3
EKG/EEG $304 or $40 per outpatient visit $20 per visit Basic Medical3
Radiation, Chemotherapy, Dialysis No copayment No copayment Basic Medical3
Womens Health Care/OB GYN:
Screenings and $304 or $40 per outpatient visit $20 per visit Basic Medical3
Maternity-Related Lab Tests
Mammograms No copayment No copayment Basic Medical3
Pre/Postnatal Visits $20 per visit Basic Medical3
and Well-Woman Exams
Bone Density Tests $304 or $40 per outpatient visit $20 per visit Basic Medical3
Breastfeeding Services No copayment for pre/postnatal
and Equipment counseling and equipment
purchase from a participating
provider; one double-electric
breast pump per birth
Family Planning Services $20 per visit Basic Medical3
Infertility Services $304 or $40 per outpatient visit $20 per visit; no copayment at Basic Medical3
designated Centers of Excellence 5
Contraceptive Drugs and Devices No copayment for certain Basic Medical3

FDA-approved oral contraception
methods (including outpatient
surgical implantation) and counseling
Inpatient Hospital Surgery No copayment6 No copayment Basic Medical3
Outpatient Surgery $404 or $60 per visit $20 per visit7 Basic Medical3
Emergency Room $604 or $70 per visit8 No copayment Basic Medical3,9
Urgent Care $304 or $40 per outpatient visit10 $20 per visit Basic Medical3
Ambulance No copayment11 $35 per trip12 $35 per trip12
Mental Health $20 per visit Applicable annual deductible,3
Practitioner Services 80% of usual and customary;
after applicable coinsurance max,3
100% of usual and customary
(see pages 20-21 for details).
Approved Facility No copayment 90% of billed charges; after
Mental Health Services applicable coinsurance max,3
covered in full (see pages 20-21
for details).
Outpatient Drug/ $20 per visit to approved Applicable annual deductible,3
Alcohol Rehabilitation Structured Outpatient 80% of usual and customary;
Rehabilitation Program after applicable coinsurance max,3
100% of usual and customary
(see pages 20-21 for details).
1 Inpatientstays at network hospitals are paid in full. Provider charges 8 Copayment waived if admitted.
are covered under the Medical/Surgical Program. Non-network 9 Attending emergency room physicians and providers who administer
hospital coverage provided subject to coinsurance (see page 20). or interpret radiological exams, laboratory tests, electrocardiograms
2 Copayment waived for preventive services under PPACA. See and/or pathology services are paid in full. Other providers are
www.hhs.gov/healthcare/rights/preventive-care or NYSHIP Online for considered under the Basic Medical Program and are not subject
details. Diagnostic services require plan copayment or coinsurance. to deductible or coinsurance.
3 See Cost Sharing (beginning on page 20) for Basic Medical information. 10 At a hospital-owned urgent care facility only.
4 Copayment for CSEA and UCS enrollees only. 11 If service is provided by admitting hospital.
5 Certainqualified procedures require precertification and are subject 12 Ambulance transportation to the nearest hospital where emergency
to a $50,000 lifetime allowance. care can be performed is covered when the service is provided by a
6 Preadmission certification required. licensed ambulance service and the type of ambulance
transportation is required because of an emergency situation.
7 In
outpatient surgical locations (Medical/Surgical Program), the
copayment for the facility charge is $30 per visit or Basic Medical
benefits apply, depending upon the status of the center. (Check
with the center or The Empire Plan program administrators.)
ACTIVES CHOICES 2017

25
The Empire Plan
Inpatient Drug/ No copayment 90% of billed charges; after
Alcohol Rehabilitation applicable coinsurance max,3

covered in full (see pages 20-21
for details).
Durable Medical Equipment No copayment (HCAP) 0% of network allowance (see the
5
Empire Plan Certificate/Reports).
Prosthetics No copayment13 Basic Medical3,13 $1,500 lifetime
maximum benefit for prosthetic
wigs not subject to deductible
or coinsurance
Orthotic Devices No copayment13 Basic Medical3,13
External Mastectomy Prostheses No network benefit. See Paid-in-full benefit for one single or
nonparticipating provider. double prosthesis per calendar year
under Basic Medical, not subject
to deductible or coinsurance3,13
(precertification may be required).
Rehabilitative Care No copayment as an inpatient; Physical or occupational therapy $250 annual deductible,
(not covered in a skilled nursing $20 per visit for outpatient $20 per visit (MPN) 50% of network allowance
facility if Medicare primary) physical therapy following
related surgery or hospitalization Speech therapy $20 per visit Basic Medical3
Diabetic Supplies No copayment (HCAP) 50% of network allowance (see
the Empire Plan Certificate/Reports).
Insulin and Oral Agents
(covered under the
Prescription Drug Program,
subject to drug copayment)
Diabetic Shoes $500 annual maximum benefit 75% of network allowance up
to an annual maximum benefit
of $500 (see the Empire Plan
Certificate/Reports).
Hospice No copayment, no limit 1 0% of billed charges up
to the combined annual
coinsurance maximum
Skilled Nursing Facility No copayment up to
365 benefit days14
Prescription Drugs
(see pages 22-23)
Specialty Drugs (see pages 22-23)
Additional Benefits
Dental (preventive) Not covered Not covered
Vision (routine only) Not covered Not covered
Hearing Aids o network benefit.
N Up to $1,500 per aid per ear
See nonparticipating provider. every 4 years (every 2 years for
children) if medically necessary
Annual Out-of-Pocket Maximum Individual coverage: $2,500 for the Prescription Drug Program.15 Not available
$4,650 shared maximum for the Hospital, Medical/Surgical and
Mental Health/Substance Abuse Programs
Family coverage: $5,000 for the Prescription Drug Program.15
$9,300 shared maximum for the Hospital, Medical/Surgical and
Mental Health/Substance Abuse Programs
Out-of-Area Benefit Benefits for covered services are available worldwide.
24-hour NurseLineSM for health information and support at 1-877-7-NYSHIP (1-877-769-7447).
Voluntary disease management programs available for conditions such as asthma, attention deficit hyperactivity disorder (ADHD), cardiovascular
disease, chronic kidney disease (CKD), chronic obstructive pulmonary disease, congestive heart failure, depression, diabetes and eating disorders.
Diabetes education centers for enrollees who have a diagnosis of diabetes.
For more information regarding covered vaccines, tests and screenings, see the Empire Plan Preventive Care Coverage Chart on NYSHIP
Online under Publications. Or, visit www.hhs.gov/healthcare/rights/preventive-care.
1 Inpatientstays at network hospitals are paid in full. Provider charges 3 See Cost Sharing (beginning on page 20) for Basic Medical information.
are covered under the Medical/Surgical Program. Non-network 13 Benefit paid up to cost of device meeting individuals functional need.
hospital coverage provided subject to coinsurance (see page 20).
14 Precertification required.
2 Copayment waived for preventive services under PPACA. See
www.hhs.gov/healthcare/rights/preventive-care or NYSHIP Online for 15 Does not apply to Medicare-primary enrollees.
ACTIVES CHOICES 2017

details. Diagnostic services require plan copayment or coinsurance.
27
Benefits Enrollee Cost Benefits Enrollee Cost
Office Visits $25 per visit Outpatient Surgery
($5 for children to age 26) Hospital $50 per visit
Annual Adult Routine Physicals No copayment Physicians Office $50 copayment
Well Child Care No copayment or 20% coinsurance, whichever is less
Specialty Office Visits $40 per visit Outpatient Surgery Facility $40 physician and
$50 facility per visit
Diagnostic/Therapeutic Services
Radiology $40 per visit Emergency Room $100 per visit
(waived if admitted within 24 hours)
Lab Tests No copayment
Pathology No copayment Urgent Care Facility $35 per visit
EKG/EEG No copayment Ambulance $100 per trip
Radiation $25 per visit Outpatient Mental Health
Chemotherapy $25 for Rx injection Individual, unlimited $40 per visit
and $25 office copayment Group, unlimited $40 per visit
(max two copayments per day)
Inpatient Mental Health No copayment
Womens Health Care/OB GYN unlimited
Pap Tests No copayment Outpatient Drug/Alcohol Rehab $25 per visit
Mammograms No copayment unlimited
Prenatal Visits No copayment Inpatient Drug/Alcohol Rehab No copayment
Postnatal Visits No copayment unlimited
Bone Density Tests No copayment (routine), Durable Medical Equipment 50% coinsurance
$40 copayment (diagnostic)
Prosthetics 50% coinsurance
Family Planning Services $25 PCP,
Orthotics 50% coinsurance
$40 specialist per visit
Rehabilitative Care, Physical,
Infertility Services Applicable physician/
Speech and Occupational Therapy
facility copayment
Inpatient, max 60 days No copayment
Contraceptive Drugs Applicable Rx copayment 1
Outpatient Physical or $40 per visit
Contraceptive Devices Applicable copayment/ Occupational Therapy,
coinsurance 1
max 30 visits for all outpatient services combined
Inpatient Hospital Surgery Outpatient Speech Therapy, $40 per visit
Physician No copayment max 30 visits for all outpatient services combined
Facility No copayment Diabetic Supplies $25 per item
up to a 30-day supply
Insulin and Oral Agents $25 per prescription
up to a 30-day supply
Diabetic Shoes 50% coinsurance
one pair per year when medically necessary
1 Generic oral contraceptives and certain OTC contraceptive devices are covered in full in accordance with the
Affordable Care Act.

Benefits Enrollee Cost Participating Physicians
Hospice, max 210 days No copayment With more than 3,200 providers available, Blue
Choice offers you more choice of doctors than
Skilled Nursing Facility No copayment any other area HMO. Talk to your doctor about
max 45 days per admission, 360-day lifetime max whether Blue Choice is the right plan for you.
Prescription Drugs Affiliated Hospitals
Retail, 30-day supply $10 Tier 1, All operating hospitals in the Blue Choice service
$30 Tier 2, $50 Tier 3 2 area are available to you, plus some outside the
Mail Order, up to 90-day supply $20 Tier 1, service area. Please call the number provided for
$60 Tier 2, $100 Tier 3 2 a directory, or visit www.excellusbcbs.com.
You can purchase a 90-day supply of a Pharmacies and Prescriptions
maintenance medication at a retail pharmacy for Fill prescriptions at any of our more than 60,000
a $30, $90 or $150 copayment. You are limited participating pharmacies nationwide. Simply show
to a 30-day supply for the first fill. Coverage the pharmacist your ID card. Blue Choice offers
includes fertility drugs, injectable and self- convenient mail order services for select
injectable medications and enteral formulas. maintenance drugs. Blue Choice offers an
incented formulary.
Specialty Drugs
Designated specialty drugs are covered only at a Medicare Coverage
network specialty pharmacy, subject to the same Medicare-primary NYSHIP enrollees must enroll in
days supply and cost-sharing requirements as the Medicare Blue Choice, our Medicare Advantage
retail benefit, and cannot be filled via mail order. Plan. To qualify, you must be enrolled in Medicare
A current list of specialty medications and Parts A and B and live in the service area. Some
pharmacies is available at www.excellusbcbs.com. copayments will vary.
Additional Benefits
Important Note: Only participating providers in
Annual Out-of-Pocket Maximum
the NYS counties listed below are part of this
(In-Network Benefits).......................... $6,350 Individual,
HMOs network within NYSHIP. Before receiving
$12,700 Family per year
care, please be sure to check that your provider
Dental 3................................................................................. $40 per visit
participates with this HMOs NYSHIP network.
Vision4................................................................................... $40 per visit
NYSHIP Code Number 066
Hearing Aids................................................ Children to age 19: A Network HMO serving individuals living or
Covered in full for up to two hearing aids every working in the following counties: Livingston,
three years Monroe, Ontario, Seneca, Wayne and Yates.
Out of Area..................................................................Our BlueCard
and Away From Home Care Programs cover Blue Choice
routine and urgent care while traveling, for 165 Court Street, Rochester, NY 14647
students away at school, members on extended For information:
out-of-town business and for families living apart. Blue Choice: 1-800-499-1275
Maternity TTY: 1-800-421-1220
(Physicians charge for delivery)........$50 copayment
Medicare Blue Choice: 1-877-883-9577
Plan Highlights for 2017 Website: www.excellusbcbs.com
Laboratory and pathology services are covered
in full. We deliver high-quality coverage, plus
discounts on services that encourage you to keep
a healthy lifestyle.
2 Ifyour doctor prescribes a brand-name drug when an FDA-approved generic equivalent is available, you pay the
difference between the cost of the generic and the brand-name drug, plus any applicable copayments.
3 Coverage for accidental injury to sound and natural teeth and for care due to congenital disease or anomaly; routine
care not covered.
4 Coverage for exams to treat a disease or injury; routine care not covered.

Office Visits $20 per visit Urgent Care Facility $35 per visit
Annual Adult Routine Physicals No copayment Ambulance $100 per trip
Well Child Care No copayment Outpatient Mental Health
Specialty Office Visits $20 per visit Individual $20 per visit
Diagnostic/Therapeutic Services unlimited when medically necessary
Radiology $20 per visit Group $20 per visit
Lab Tests No copayment 1 unlimited when medically necessary
Pathology No copayment Inpatient Mental Health No copayment
unlimited when medically necessary
EKG/EEG $20 per visit
Radiation $20 per visit Outpatient Drug/Alcohol Rehab $20 per visit
unlimited when medically necessary
Chemotherapy $20 per visit
Inpatient Drug/Alcohol Rehab No copayment
Womens Health Care/OB GYN unlimited when medically necessary
Pap Tests No copayment
Durable Medical Equipment 50% coinsurance
Mammograms No copayment
Prenatal Visits
2 $20 for initial visit only Prosthetics 20% coinsurance
Postnatal Visits No copayment Orthotics 20% coinsurance
Bone Density Tests No copayment Rehabilitative Care, Physical,
Speech and Occupational Therapy
Family Planning Services3 $20 per visit
Infertility Services4 $20 per visit Outpatient Physical or $20 per visit
Contraceptive Drugs5 No copayment 6 Occupational Therapy,
Contraceptive Devices No copayment 6 max 20 visits7
Outpatient Speech Therapy, $20 per visit
Inpatient Hospital Surgery No copayment
max 20 visits7
Outpatient Surgery
Diabetic Supplies $20 per item
Hospital $100 per visit
Physicians Office $20 per visit Insulin and Oral Agents $20 per item
Outpatient Surgery Facility $100 per visit Diabetic Shoes Not covered
Emergency Room $100 per visit Hospice, max 210 days per year No copayment
(waived if admitted)
1 Forservices at a standalone Quest lab or outpatient hospital that participates as a Quest Diagnostics hospital draw site.
Lab services performed in conjunction with outpatient surgery or an emergency room visit also paid in full.
2 One-time $20 copayment to confirm pregnancy. No copayment for inpatient maternity care or gestational
diabetes screenings.
3 Coverage is provided for diagnostic testing and procedures in conjunction with artificial insemination. The copayments,
coinsurance and deductible under your policy, which apply to hospital, medical or prescription drug benefits, are
applicable to the benefits covered under family planning services.
4 For services to diagnose and treat infertility. See Additional Benefits for artificial insemination.
5 Coverage is provided for prescription drugs approved by the FDA for use in treatment associated with contraception.

Benefits Enrollee Cost Plan Highlights for 2017
Skilled Nursing Facility No copayment Wellness programs, online and community-based.
max 50 days Acupuncture, massage therapy, nutritional
counseling, fitness centers, spa discounts.
Prescription Drugs
Participating Physicians
Retail, 30-day supply6 $5 Tier 1,
You have access to 3,000+ physicians/healthcare
$30 Tier 2, $60 Tier 3
professionals.
Mail Order, 90-day supply $12.50 Tier 1,
$75 Tier 2, $150 Tier 3 Affiliated Hospitals
You may receive care at all western New York
Includes prenatal vitamins, fertility drugs, hospitals and other hospitals if medically necessary.
injectable/self-injectable medications, insulin and
oral diabetic agents. May require prior approval. Pharmacies and Prescriptions
Our network includes 45,000 participating
Specialty Drugs pharmacies. Prescriptions filled up to 30-day supply.
Available through mail order at the applicable BlueCross BlueShield offers an incented formulary.
copayment.
Medicare Coverage
Additional Benefits Medicare-primary enrollees are required to enroll
Annual Out-of-Pocket Maximum in Senior Blue HMO. To qualify, you must enroll in
(In-Network Benefits).......................... $3,000 Individual, Medicare Parts A and B and live in one of the
$6,000 Family per year counties below.
Dental........................... 20% discount at select providers,
free second annual exam Important Note: Only participating providers in the
Vision..................... VisionPLUS Program (details below) NYS counties listed below are part of this HMOs
Hearing Aids.............................................. Discounts available network within NYSHIP. Before receiving care,
at select locations please be sure to check that your provider
Out of Area.............................................. Worldwide coverage
for emergency and urgent care through the NYSHIP Code Number 067
BlueCard Program. Guest membership for An IPA HMO serving individuals living or working
routine care away from home that enables in the following counties: Allegany, Cattaraugus,
members on extended business trips or family Chautauqua, Erie, Genesee, Niagara, Orleans
members away at school to join a nearby Blue and Wyoming.
HMO for the same benefits.
BlueCross BlueShield of Western New York
VisionPLUS Program................................. Includes routine P.O. Box 80, Buffalo, NY 14240-0080
eye exam covered in full and participating
VisionPLUS provider discounts. Low copayments For information:
on frames, lenses and a discount on contact BlueCross BlueShield of Western New York:
lenses and supplies. 716-887-8840 or 1-877-576-6440
Artificial Insemination........................... 20% coinsurance TTY: 711
Other artificial means to induce pregnancy Website: www.bcbswny.com
(in-vitro embryo transfer, etc.) are not covered.
Wellness Services............................. $300 Wellness Card
allowance for use at participating providers
6 No copayment for contraceptive drugs and devices unless a generic equivalent is available and you are subject to a
$30 (Tier 2) or $60 (Tier 3) copayment. A mail-order supply costs 2.5 times the applicable copayment.
7 Twenty visits in aggregate for physical therapy, occupational therapy and speech therapy.

Office Visits $20 per visit Outpatient Mental Health
Annual Adult Routine Physicals No copayment Individual, unlimited $20 per visit
Well Child Care No copayment Group, unlimited $20 per visit
Specialty Office Visits $20 per visit Inpatient Mental Health No copayment
Diagnostic/Therapeutic Services unlimited
Radiology $20 per visit 1 Outpatient Drug/Alcohol Rehab $20 per visit
Lab Tests $20 per visit 2 unlimited
Pathology $20 per visit 2 Inpatient Drug/Alcohol Rehab No copayment
unlimited
Radiation $20 per visit Durable Medical Equipment 50% coinsurance
Chemotherapy $20 per visit Prosthetics 50% coinsurance
Womens Health Care/OB GYN Orthotics4 50% coinsurance
Pap Tests No copayment Rehabilitative Care, Physical,
Mammograms No copayment Speech and Occupational Therapy
Prenatal Visits No copayment Inpatient, max 60 days No copayment
Postnatal Visits No copayment Outpatient Physical or $20 per visit
Occupational Therapy,
Bone Density Tests No copayment max 30 visits each per calendar year
Family Planning Services $20 per visit Outpatient Speech Therapy, $20 per visit
Infertility Services $20 per visit max 20 visits per calendar year
Contraceptive Drugs No copayment 3 Diabetic Supplies
Contraceptive Devices No copayment 3 Retail, 30-day supply $20 per item
Mail-Order, 90-day supply $50 per item
Insulin and Oral Agents
Outpatient Surgery
Retail, 30-day supply $20 per item
Mail-Order, 90-day supply $50 per item
Physicians Office $20 per visit
Outpatient Surgery Facility $75 per visit Diabetic Shoes $20 per pair
Emergency Room $50 per visit
(waived if admitted within 24 hours) Hospice, max 210 days No copayment
Urgent Care Facility $25 per visit Skilled Nursing Facility

max 45 days No copayment
Ambulance $50 per trip
1 Waived if provider is a preferred center.

2 Waived if provider is a designated laboratory.
3 OTC contraceptives with a written physician order/prescription will be reimbursed at no member cost share. OTC
contraceptives without a prescription will not be covered. Non-formulary contraceptives require prior authorization
to be covered at no copayment. If not approved, 100 percent member liability applies.
4 Excludes shoe inserts.

Prescription Drugs CDPHP has nearly 10,000 participating practitioners
and providers.
Retail, 30-day supply $5 Tier 1,
$30 Tier 2, $50 Tier 3 Affiliated Hospitals
Mail Order, 90-day supply $12.50 Tier 1, CDPHP is affiliated with most major hospitals in
$75 Tier 2, $125 Tier 3 our service area. An out-of-network facility or
Center of Excellence can be approved for special
Coverage includes injectable and self-injectable care needs.
medications, fertility drugs and enteral formulas.
OTC formulary drugs are subject to Tier 1 Pharmacies and Prescriptions
copayment. By law, generics match brand-name CDPHP offers a closed formulary with few excluded
strength, purity and stability. Ask your doctor drugs. Log in to Rx Corner at www.cdphp.com to
about generic alternatives. find participating pharmacies and view claims.
Mail order saves money; find forms online or call
Specialty Drugs 518-641-3700 or 1-800-777-2273.
Certain specialty drugs, regardless of tier,
require prior approval, are subject to clinical Medicare Coverage
management programs and must be filled by a Medicare-primary NYSHIP retirees and dependents
network specialty pharmacy. Contact Caremark must enroll in CDPHP Group Medicare Rx (HMO) or
Specialty Pharmacy Services at 1-800-237-2767. Group Medicare (HMO). To qualify, you must have
A representative will work with your doctor and Medicare Parts A and B and live in one of the
arrange delivery. For more information, visit counties listed below.
Rx Corner at www.cdphp.com.
Additional Benefits
HMOs network within NYSHIP. Before receiving
Dental................................................................................... Not covered
Vision..................................................................................... Not covered NYSHIP Code Number 063
An IPA HMO serving individuals living or working
Hearing Aids................................................................. Not covered
in the following counties: Albany, Columbia, Fulton,
Out of Area.....................Coverage for emergency care Greene, Montgomery, Rensselaer, Saratoga,
out of area. College students are also covered Schenectady, Schoharie, Warren and Washington.
for preapproved follow-up care.
Allergy Injections............................................... No copayment
Diabetes Self-management in the following counties: Broome, Chenango,
Education.....................................................................$20 per visit Essex, Hamilton, Herkimer, Madison, Oneida,
Glucometer................................................................... $20 per item Otsego and Tioga.
Acupuncture 10 visits per plan year....... $20 per visit
Diabetic Prevention Program.............. No copayment An IPA HMO serving individuals living or working
Reimbursement up to $500 per subscriber in the following counties: Delaware, Dutchess,
per year Orange and Ulster.
Plan Highlights for 2017 Capital District Physicians Health Plan, Inc. (CDPHP)
CDPHP InMotionSM is a free mobile smartphone 500 Patroon Creek Boulevard, Albany, NY
fitness application with GPS technology to map your 12206-1057
runs; view or share results at inmotion.cdphp.com.
With Rx for Less, get deep discounts on specified For information:
generic prescriptions filled at any CVS, Walmart or Member Services: 518-641-3700 or 1-800-777-2273
Price Chopper. Dedicated member services reps are TTY: 1-877-261-1164
available weekdays from 8 a.m. to 8 p.m. We also Website: www.cdphp.com
have health experts who can find the best program
or service for you; simply call 1-888-94-CDPHP.

Office Visits $20 per visit Emergency Room $75 per visit
Annual Adult Routine Physicals No copayment (waived if admitted within 24 hours)
Well Child Care No copayment Urgent Care Facility $20 per visit
Specialty Office Visits $20 per visit Ambulance No copayment
Diagnostic/Therapeutic Services Outpatient Mental Health
Radiology1 $20 per visit Individual,1 unlimited $20 per visit 3
Lab Tests No copayment Group,1 unlimited $20 per visit 3
Pathology No copayment Inpatient Mental Health1 No copayment
EKG/EEG $20 per visit unlimited
Radiation No copayment Outpatient Drug/Alcohol Rehab1 $20 per visit 4
Chemotherapy No copayment Inpatient Drug/Alcohol Rehab1 No copayment
Womens Health Care/OB GYN as many days as medically necessary
Pap Tests No copayment Durable Medical Equipment1 20% coinsurance
Mammograms No copayment Prosthetics1 20% coinsurance
Prenatal Visits No copayment
Orthotics1 20% coinsurance
Postnatal Visits No copayment
Bone Density Tests No copayment Speech and Occupational Therapy
Family Planning Services $20 per visit Inpatient, max 30 days No copayment
Infertility Services $20 per visit Outpatient Physical
or Occupational Therapy5 $20 per visit
Outpatient Speech Therapy5 $20 per visit
Contraceptive Devices No copayment
Diabetic Supplies6 $20 per item
Inpatient Hospital Surgery1 No copayment
Insulin and Oral Agents6 $20 per item
Outpatient Surgery
Hospital $75 per visit Diabetic Shoes $20 per pair
unlimited pairs when medically necessary
Physicians Office $20 per visit
Hospice No copayment
Outpatient Surgery Facility1 $75 per visit
210 days maximum per lifetime
1 Empires network provider must precertify in-network services or services may be denied; Empire network providers cannot
bill members beyond in-network copayment (if applicable) for covered services. For ambulatory surgery, preapproval is
required for cosmetic/reconstructive procedures, outpatient transplants and ophthalmological or eye-related procedures.
2 Certain prescription contraceptives are covered in full in accordance with the Affordable Care Act. To be covered in full,
the prescription must be a generic drug or brand-name drug with no generic equivalent and filled at a network pharmacy.
3 No copayment for visits at an outpatient mental health facility.
4 No copayment for visits in an outpatient facility.
5 Up to 30 visits per calendar year combined between home, office or outpatient facility.
6 For diabetic DME/supplies, copayment applies for up to 52 combined items annually, then covered at 100 percent.

Benefits Enrollee Cost other hospitals to meet special needs. See our
web site for a list of all participating hospitals.
Skilled Nursing Facility1 No copayment
60 days maximum per calendar year Pharmacies and Prescriptions
Enrollees with prescription coverage can use local
Prescription Drugs
and national pharmacies. Members who use our
mail service pay only two copayments for each
$25 Tier 2, $50 Tier 3
90-day supply of medication. Coverage includes
Mail Order, 90-day supply $20 Tier 1, contraceptive drugs and devices, injectable and
$50 Tier 2, $100 Tier 3 self-injectable drugs, fertility drugs and enteral
Specialty Drugs formulas. Empire BlueCross BlueShield HMO offers
Specialty medications only dispensed in 30-day an incented formulary.
supplies. Enrollees are required to pay the Medicare Coverage
applicable copayment for each 30-day supply. Medicare-primary enrollees are required to enroll
in MediBlue, the Empire BlueCross BlueShield
Additional Benefits
Medicare Advantage Plan. To qualify, you must
be enrolled in Medicare Parts A and B and live in
one of the counties listed below.
Dental................................................................................... Not covered
Vision..................................................................................... Not covered
Hearing Aids................................................................. Not covered HMOs network within NYSHIP. Before receiving
Out of Area............. The Guest Membership Program care, please be sure to check that your provider
offers temporary coverage through the local participates with this HMOs NYSHIP network.
BlueCross and/or BlueShield HMO plan for
contract holders away from home more than NYSHIP Code Number 280
90 days but less than 180 days and for full-time An IPA HMO serving individuals living or working
students/other eligible dependents away from in the following counties: Albany, Clinton,
home more than 90 days. The BlueCard Columbia, Delaware, Essex, Fulton, Greene,
Program covers enrollees traveling outside the Montgomery, Rensselaer, Saratoga, Schenectady,
service area who may encounter an urgent or Schoharie, Warren and Washington.
emergent situation and who are not enrolled in NYSHIP Code Number 290
the Guest Membership Program. An IPA HMO serving individuals living or working
LiveHealth Online...................................................$20 per visit in the following counties: Bronx, Kings, Nassau,
New York, Queens, Richmond, Rockland, Suffolk
Plan Highlights for 2017 and Westchester.
LiveHealth Online is a convenient way for you
to interact with a doctor via live, two-way video NYSHIP Code Number 320
on your computer or mobile device. Empire An IPA HMO serving individuals living or working
BlueCross BlueShield HMO provides a full range in the following counties: Dutchess, Orange,
of benefits including low out-of-pocket costs. Visit Putnam, Sullivan and Ulster.
www.empireblue.com for a list of your claims and
Empire BlueCross BlueShield HMO
payment status, email messages, your personal
11 Corporate Woods Boulevard, P.O. Box 11800
profile and healthcare provider information.
Albany, NY 12211-0800
Our network provides access to more than 65,000 For information:
provider locations. Empire BlueCross BlueShield HMO: 1-800-453-0113
For Medicare Advantage Plan
Affiliated Hospitals Preenrollment Information: 1-866-205-6551
Members are covered through a comprehensive
TTY: 1-800-241-6894
network of area hospitals (more than 140) to
which their participating physician has admitting Website: www.empireblue.com
privileges. HMO members may be directed to

an EmblemHealth Company

Office Visits $5 per visit Inpatient Mental Health No copayment
Annual Adult Routine Physicals No copayment unlimited
Well Child Care No copayment Outpatient Drug/Alcohol Rehab $5 PCP,
Specialty Office Visits $10 per visit unlimited $10 specialist per visit
Diagnostic/Therapeutic Services Inpatient Drug/Alcohol Rehab No copayment

unlimited
Radiology No copayment
Lab Tests No copayment Durable Medical Equipment No copayment
Pathology No copayment Prosthetics No copayment
EKG/EEG No copayment Orthotics No copayment
Radiation No copayment Rehabilitative Care, Physical,
Chemotherapy $10 per visit Speech and Occupational Therapy
Womens Health Care/OB GYN
Pap Tests No copayment Outpatient Physical or $10 per visit
Mammograms No copayment
max 90 visits for all
Prenatal Visits No copayment outpatient rehabilitative care
Postnatal Visits No copayment Outpatient Speech Therapy, $10 per visit
Bone Density Tests No copayment max 90 visits for all
outpatient rehabilitative care
Family Planning Services $5 PCP,
$10 specialist per visit Diabetic Supplies $5 per 34-day supply
Infertility Services $10 per visit Insulin and Oral Agents $5 per 34-day supply
Contraceptive Drugs1 No copayment Diabetic Shoes2 No copayment
when medically necessary
Contraceptive Devices1 No copayment
Hospice, max 210 days No copayment
Skilled Nursing Facility No copayment
Outpatient Surgery
unlimited
Hospital No copayment
Physicians Office $5 PCP, Prescription Drugs
$10 specialist per visit Retail, 30-day supply $5 Tier 1, $20 Tier 2
Outpatient Surgery Facility No copayment Mail Order, 90-day supply $7.50 Tier 1,
$30 Tier 2
(waived if admitted) Subject to drug formulary, includes fertility
drugs, injectable and self-injectable medications
Urgent Care Facility $5 copayment and enteral formulas. Copayments reduced by
Ambulance No copayment 50 percent when utilizing EmblemHealth mail
order service. Up to a 90-day supply of generic
Outpatient Mental Health No copayment
or brand-name drugs may be obtained.
unlimited
1 Covered for FDA-approved contraceptive drugs and devices only.

2 Precertification must be obtained from the participating vendor prior to purchase.

Specialty Drugs Affiliated Hospitals
Coverage provided through EmblemHealth HIP Prime members have access to more than
Specialty Pharmacy Program. Specialty drugs 100 of the areas leading hospitals, including
include injectables and oral agents that are major teaching institutions.
more complex to administer, monitor and store Pharmacies and Prescriptions
in comparison with traditional drugs. Specialty Filling a prescription is easy with more than
drugs require prior approval, which can be 40,000 participating pharmacies nationwide,
obtained by the HIP prescribing physician. including more than 4,700 participating
Specialty drugs are subject to the applicable pharmacies throughout New York State. HIP
Rx copay, Rx formulary and distribution from Prime members have access to a mail order
our preferred specialty pharmacy. program through Express Scripts. The HIP Prime
Additional Benefits Plan offers a closed formulary. Tier 1 includes
Annual Out-of-Pocket Maximum generic drugs; Tier 2 includes brand-name drugs.
(In-Network Benefits).......................... $6,850 Individual, Medicare Coverage
$13,700 Family per year Retirees who are not Medicare-eligible are offered
Dental................................................................................... Not covered the same coverage as active employees. Medicare-
Vision............................................................................... No copayment primary retirees who reside in NYSHIP-approved
downstate service counties are required to enroll in
Hearing Aids.....................................Cochlear implants only the VIP Premier (HMO) Medicare Plan, a Medicare
Out of Area...... Covered for emergency services only Advantage Plan that provides Medicare benefits
Eyeglasses........................................................................$35 per pair and more.
one pair every 24 months for selected frames
Laser Vision Correction (LASIK).... Discount program Important Note: Only participating providers in
Fitness Program......................................... Discount program the NYS counties listed below are part of this
Alternative Medicine Program..... Discount program HMOs network within NYSHIP. Before receiving
Artificial Insemination......................................... $10 per visit participates with this HMOs NYSHIP network.
Prostate Cancer Screening.................... No copayment
Dialysis Treatment.................................................. $10 per visit
A Network and IPA HMO serving individuals living
Plan Highlights for 2017 or working in the following counties: Bronx, Kings,
The HIP Prime network has more than 39,000 Nassau, New York, Queens, Richmond, Suffolk
physicians practicing in 105,000 locations and and Westchester.
an overall network of 71,000 providers in more NYSHIP Code Number 220
than 168,000 locations. HIP (an EmblemHealth
company) has been providing health benefits
in the following counties: Albany, Columbia,
to hardworking New Yorkers for nearly seven
Greene, Rensselaer, Saratoga, Schenectady,
decades and is committed to building a healthy
Warren and Washington.
future for you and your family. More information
is available at www.emblemhealth.com. NYSHIP Code Number 350
Participating Physicians An IPA HMO serving individuals living or working
The HIP Prime network offers the choice of a in the following counties: Delaware, Dutchess,
traditional network of independent physicians Orange, Putnam, Sullivan and Ulster.
who see patients in their own offices, as well as EmblemHealth
providers in physician group practices that meet 55 Water Street, New York, NY 10041
most, if not all, of a members medical needs
under one roof. Group practices offer services For information:
in most major specialties such as cardiology and Customer Service: 1-800-447-8255
ophthalmology, plus ancillary services like lab TTY: 1-888-447-4833
tests, X-rays and pharmacy services. Website: www.emblemhealth.com

Office Visits $25 per visit Urgent Care Facility $35 per visit
Specialty Office Visits $40 per visit Individual, unlimited $40 per visit
Diagnostic/Therapeutic Services Group, unlimited $40 per visit
Radiology $40 per visit Inpatient Mental Health No copayment
Lab Tests No copayment unlimited
Pathology No copayment Outpatient Drug/Alcohol Rehab $25 per visit
EKG/EEG No copayment unlimited
Radiation $25 per visit Inpatient Drug/Alcohol Rehab No copayment
Chemotherapy $25 per visit unlimited
Womens Health Care/OB GYN Durable Medical Equipment 50% coinsurance
Pap Tests No copayment Prosthetics 50% coinsurance
Mammograms No copayment Orthotics 50% coinsurance
Postnatal Visits No copayment Speech and Occupational Therapy
Bone Density Tests $25 per visit Inpatient, max 60 days No copayment
Family Planning Services $25 PCP, Outpatient Physical or $40 per visit
$40 specialist per visit Occupational Therapy,
Infertility Services Applicable physician/ outpatient services combined
facility copayment
Outpatient Speech Therapy, $40 per visit
Contraceptive Devices Applicable copayment/ outpatient services combined
coinsurance 1
Diabetic Supplies $25 per item
Inpatient Hospital Surgery 30-day supply
Physician $200 copayment or Insulin and Oral Agents $25 per item
20% coinsurance, whichever is less 30-day supply
Facility No copayment Diabetic Shoes 50% coinsurance
Outpatient Surgery three pairs per year when medically necessary
Hospital $40 physician copayment per visit Hospice, max 210 days No copayment
Physicians Office $50 copayment or Skilled Nursing Facility No copayment
20% coinsurance, whichever is less max 45 days per calendar year
Outpatient Surgery Facility $50 per visit
(waived if admitted)
1 Generic oral contraceptives and certain OTC contraceptive devices covered in full in accordance with the
Affordable Care Act.

Prescription Drugs HMOBlue is affiliated with more than 4,700
physicians and health care professionals.
$30 Tier 2, $50 Tier 3 2 Affiliated Hospitals
Mail Order, 90-day supply $20 Tier 1, All hospitals within our designated service area
$60 Tier 2, $100 Tier 3 2 participate with HMOBlue. Members may be
directed to other hospitals to meet special needs
Coverage includes injectable and self-injectable when medically necessary.
medications, fertility drugs and enteral formulas.
Pharmacies and Prescriptions
Specialty Drugs HMOBlue members may purchase prescription
Specialty medications after the initial first fill must drugs from more than 60,000 participating FLRx
be purchased from one of our participating Network pharmacies nationwide. We offer an
specialty pharmacies. A current list of specialty incented formulary.
medications and pharmacies is available on our
Medicare Coverage
web site.
HMOBlue offers the same benefits to Medicare-
Additional Benefits eligible NYSHIP enrollees. HMOBlue coordinates
Annual Out-of-Pocket Maximum coverage with Medicare.
$12,700 Family per year Important Note: Only participating providers in
Dental................................................................................... Not covered the NYS counties listed below are part of this
Vision............................................ $40 per visit for eye exams HMOs network within NYSHIP. Before receiving
associated with disease or injury care, please be sure to check that your provider
Hearing Aids................................................ Children to age 19:
Covered in full for up to two hearing aids every NYSHIP Code Number 072
three years; $40 copayment per visit for fittings An IPA HMO serving individuals living or working in
Out of Area..................................................... The BlueCard and the following counties: Broome, Cayuga, Chemung,
Away From Home Care Programs provide routine Cortland, Onondaga, Oswego, Schuyler, Steuben,
and urgent care coverage while traveling, for Tioga and Tompkins.
students away at college, members on extended NYSHIP Code Number 160
out-of-town business and families living apart. An IPA HMO serving individuals living or working
Hearing Exam.............................................................. $40 per visit in the following counties: Chenango, Clinton,
for routine (once every 12 months) and diagnostic Delaware, Essex, Franklin, Fulton, Hamilton,
Maternity Herkimer, Jefferson, Lewis, Madison, Montgomery,
(Physician charge for delivery)........$200 copayment Oneida, Otsego and St. Lawrence.
or 20% coinsurance, whichever is less
Excellus BlueCross BlueShield
Smoking Cessation..........The Quit For Life program HMOBlue 072
is an award-winning support program to help you 333 Butternut Drive, Syracuse, NY 13214-1803
quit using tobacco for good. Call 1-800-442-8904
or go to www.quitnow.net/Excellus for more Excellus BlueCross BlueShield
information. HMOBlue 160
12 Rhoads Drive, Utica, NY 13502
Plan Highlights for 2017
All laboratory and pathology services are covered For information:
in full. No referrals required. Routine preventive HMOBlue Customer Service: 1-800-499-1275
services, such as adult physicals, mammograms, TTY: 1-800-421-1220
pap smears, prostate screenings and routine Website: www.excellusbcbs.com
adult immunizations are covered in full.
2 Ifa doctor selects a brand-name drug (Tier 2 or Tier 3) when an FDA-approved generic equivalent is available, the
benefit will be based on the generic drugs cost, and the member will have to pay the difference, plus any applicable
copayments. If your prescription has no approved generic available, your benefit will not be affected.

Office Visits $20 per visit Urgent Care Facility $35 per visit 4
Specialty Office Visits $20 per visit Individual, unlimited $20 per visit
Diagnostic/Therapeutic Services Group, unlimited $20 per visit
Radiology1 $20 per visit Inpatient Mental Health No copayment
Lab Tests2 $10 per visit unlimited
Pathology $10 per visit Outpatient Drug/Alcohol Rehab $20 per visit
EKG/EEG $20 per visit unlimited
Radiation1 $20 per visit Inpatient Drug/Alcohol Rehab No copayment
Chemotherapy $20 per visit unlimited
Womens Health Care/OB GYN Durable Medical Equipment 50% coinsurance
Pap Tests No copayment Prosthetics No copayment
Mammograms No copayment Orthotics5 No copayment
Postnatal Visits No copayment Speech and Occupational Therapy
Bone Density Tests No copayment Inpatient, max 45 days No copayment
Family Planning Services $20 per visit Outpatient Physical or $20 per visit
Infertility Services max 20 visits per year for all
Physician Office $20 per visit outpatient services combined
Outpatient Surgery Facility $100 per visit Outpatient Speech Therapy, $20 per visit
Contraceptive Drugs Applicable Rx copayment 3 max 20 visits per year for all
Contraceptive Devices Applicable Rx copayment 3 outpatient services combined
Inpatient Hospital Surgery No copayment Diabetic Supplies

Retail, 90-day supply $20 per item
Outpatient Surgery
Hospital $100 per visit Mail Order Not available
Physicians Office $20 per visit Insulin and Oral Agents $20 per item
or applicable Rx copayment, whichever is less
Outpatient Surgery Facility $100 per visit
Diabetic Shoes No copayment
(waived if admitted within 24 hours)
Hospice, unlimited No copayment
1 Office based: $20 copayment; hospital based: $40 copayment

2 No copayment for lab tests drawn and processed in a primary care or specialist setting.
3 Copayment applies only for select Tier 3 oral contraceptive drugs and devices.
4 Within the service area. Outside the service area: $20 copayment, plus the difference in cost between Independent
Healths payment and the providers charges, if any. $35 per visit to a participating After Hours Care Facility.
5 Excludes shoe inserts.

Benefits Enrollee Cost Plan Highlights for 2017
Skilled Nursing Facility No copayment Independent Health has led the way in providing
max 45 days western New York with innovative solutions that
set the standard for quality and service for health
Prescription Drugs plans. Weve consistently earned top ratings from
Retail, 30-day supply $5 Tier 1, NCQA, which is why you can feel comfortable
$30 Tier 2, $60 Tier 3 and confident choosing us for your health
Mail Order, 90-day supply $12.50 Tier 1, coverage needs.
$75.00 Tier 2, $150 Tier 3 Participating Physicians
Coverage includes injectable and self-injectable Independent Health is affiliated with more than
medications, fertility drugs and enteral formulas. 4,000 physicians and health care providers
throughout the eight counties of western New York.
Specialty Drugs
Benefits are provided for specialty drugs by two Affiliated Hospitals
contracted specialty pharmacy vendors, Reliance Independent Health members are covered at all
Rx Pharmacy and Walgreens Specialty Pharmacy. western New York hospitals and may be directed
Specialty drugs, available through the prescription to other hospitals when medically necessary.
drug benefit, include select high-cost injectables Pharmacies and Prescriptions
and oral agents such as oral oncology drugs. All retail pharmacies in western New York participate.
Specialty drugs require prior approval and are Members may obtain prescriptions out of the service
subject to the applicable Rx copayment based on area by using our National Pharmacy Network, which
the formulary status of the medication. Members includes 58,000 pharmacies nationwide.
pay one copayment for each 30-day supply.
Medicare Coverage
Additional Benefits Medicare-primary NYSHIP retirees must enroll in
Annual Out-of-Pocket Maximum Medicare Encompass, a Medicare Advantage Plan.
(In-Network Benefits).......................... $4,000 Individual, Copayments differ from the copayments of a NYSHIP-
$8,000 Family per year primary enrollee. Call for detailed information.
Dental...................................................................... $50 per cleaning
and 20% discount on additional services at Important Note: Only participating providers in
select providers (preventive only) the NYS counties listed below are part of this
Vision........................ $10 per visit once every 12 months HMOs network within NYSHIP. Before receiving
(routine only) care, please be sure to check that your provider
Hearing Aids.............................................. Discounts available participates with this HMOs NYSHIP network.
at select locations NYSHIP Code Number 059
Out of Area........................................ While traveling outside An IPA HMO serving individuals living or working
the service area, members are covered for in the following counties: Allegany, Cattaraugus,
emergency and urgent care situations only. Chautauqua, Erie, Genesee, Niagara, Orleans
Home Health Care, max 40 visits..........$20 per visit and Wyoming.
Eyeglasses.................................................... Discounts available Independent Health
Urgent Care in Service Area 511 Farber Lakes Drive, Buffalo, NY 14221
for After Hours Care....................................... $35 per visit
For information:
Wellness Services......................................... $275 allowance Customer Service: 1-800-501-3439
for use at a participating facility TTY: 716-631-3108
Website: www.independenthealth.com

Office Visits $25 per visit ($10 for children) 1 Outpatient Mental Health
Annual Adult Routine Physicals No copayment Individual, unlimited $25 per visit
Well Child Care No copayment Group, unlimited $25 per visit
Specialty Office Visits $40 per visit Inpatient Mental Health No copayment
Diagnostic/Therapeutic Services unlimited
Radiology $25 per visit Outpatient Drug/Alcohol Rehab $25 per visit
Lab Tests No copayment unlimited
Pathology No copayment Inpatient Drug/Alcohol Rehab No copayment
unlimited
Radiation $40 per visit Durable Medical Equipment 50% coinsurance
Chemotherapy $40 per visit Prosthetics 50% coinsurance
Womens Health Care/OB GYN Orthotics 50% coinsurance
Pap Tests No copayment Rehabilitative Care, Physical,
Mammograms No copayment Speech and Occupational Therapy
Prenatal Visits No copayment Inpatient, max 2 months No copayment
per condition
Postnatal Visits No copayment
Outpatient Physical or $40 per visit
Bone Density Tests No copayment Occupational Therapy,
Family Planning Services $25 PCP, max 30 visits for all outpatient services combined
$40 specialist per visit Outpatient Speech Therapy, $40 per visit
Infertility Services $25 PCP, max 30 visits for all outpatient services combined
$40 specialist per visit Diabetic Supplies $25 per boxed item
Contraceptive Drugs2 No copayment 3 31-day supply
Contraceptive Devices2 No copayment 3 Insulin and Oral Agents $25 per boxed item
31-day supply
Diabetic Shoes 50% coinsurance
Outpatient Surgery
unlimited pairs when medically necessary
Physicians Office $25 PCP, Hospice, max 210 days No copayment
$40 specialist per visit Skilled Nursing Facility No copayment
Outpatient Surgery Facility $40 per visit max 45 days/calendar year
Emergency Room $75 per visit Prescription Drugs

(waived if admitted) Retail, 30-day supply $10 Tier 1,
$30 Tier 2, $50 Tier 3
Urgent Care Facility $25 per visit
Mail Order, 90-day supply $25 Tier 1,
Ambulance $50 per trip $75 Tier 2, $125 Tier 3
1 PCP sick visits for children (newborn up to age 26) $10 per visit.
2 Over-the-counter contraceptives are not covered.
3 Brand-name contraceptives with generic equivalents require member payment of the difference in cost between the
generic and brand-name drugs, plus the Tier 1 copayment.

Prescription Drugs, continued Medicare Coverage
If a member requests a brand-name drug to Medicare-primary NYSHIP enrollees must enroll in
the prescribed generic drug, he/she pays the the MVP Gold Plan, MVP Health Cares Medicare
difference between the cost of the generic and Advantage Plan. Some of the MVP Gold Plans
the brand-name drug, plus the Tier 1 copayment. copayments may vary from the MVP HMO plans
Coverage includes fertility, injectable and self- copayments. The MVP HMO plan coordinates
injectable medications and enteral formulas. coverage with Medicare in the North Region (360).
Approved prescription generic contraceptive Please contact Member Services for further details.
drugs and devices and those without a generic
equivalent are covered at 100 percent under Important Note: Only participating providers in
retail and mail order. the NYS counties listed below are part of this
Specialty Drugs HMOs network within NYSHIP. Before receiving
MVP uses CVS Caremark for specialty care, please be sure to check that your provider
pharmacy services. Copayments are listed participates with this HMOs NYSHIP network.
under the Prescription Drug benefit. NYSHIP Code Number 058
Additional Benefits
in the following counties: Genesee, Livingston,
Monroe, Ontario, Orleans, Seneca, Steuben,
Wayne, Wyoming and Yates.
Dental.................................................... $25 per preventive visit NYSHIP Code Number 060
(children to age 19) An IPA HMO serving individuals living or working
Vision................................ $25 per exam every 24 months in the following counties: Albany, Columbia, Fulton,
(routine only) Greene, Hamilton, Montgomery, Rensselaer,
Saratoga, Schenectady, Schoharie, Warren
Hearing Aids................................................................. Not covered
and Washington.
Out of Area........................................ While traveling outside
the service area, coverage is provided for NYSHIP Code Number 330
emergency situations only. An IPA HMO serving individuals living or working
in the following counties: Broome, Cayuga,
Plan Highlights for 2017 Chenango, Cortland, Delaware, Herkimer,
Each MVP subscriber receives $100 HealthDollars Jefferson, Lewis, Madison, Oneida, Onondaga,
to spend on health, wellness and fitness programs. Oswego, Otsego, Tioga and Tompkins.
No referrals required. As an MVP member, you can
enjoy significant savings on a wide variety of health- NYSHIP Code Number 340
related items, plus special discounts on LASIK eye An IPA HMO serving individuals living or working
surgery, eyewear and alternative medicine. in the following counties: Dutchess, Orange, Putnam,
Rockland, Sullivan, Ulster and Westchester.
MVP Health Care provides services through more NYSHIP Code Number 360
than 28,500 participating physicians and health An IPA HMO serving individuals living or working
practitioners located throughout its service area. in the following counties: Clinton, Essex, Franklin
and St. Lawrence.
Affiliated Hospitals
MVP members are covered at participating area MVP Health Care
hospitals to which their MVP physician has admitting P.O. Box 2207, 625 State Street
privileges. MVP members may be directed to other Schenectady, NY 12301-2207
hospitals to meet special needs when medically
necessary upon prior approval from MVP. For information:
Customer Service: 1-888-MVP-MBRS (687-6277)
Pharmacies and Prescriptions TTY: 1-800-662-1220
Virtually all pharmacy chain stores and many
Website: www.mvphealthcare.com
independent pharmacies within the MVP service
area participate with MVP. Also, MVP offers
convenient mail order service for select maintenance
drugs. MVP offers an incented formulary.
NYSHIP Online
NYSHIP Online is designed to provide you with targeted information about your NYSHIP benefits. Visit the
New York State Department of Civil Service web site at www.cs.ny.gov/employee-benefits and select your
group and plan, if prompted.
Ask your HBA for a copy of the NYSHIP Online flyer, which provides helpful navigation information.
Reminder: If you are an active employee of New York State and a registered user of MyNYSHIP, you may
change your option online (excluding the Opt-out Program) during the Option Transfer Period. See your
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 employee, contact your HBA (usually located in your agencys Personnel Office or the
Business Services Center).
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 HMOs 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.

New York State
Department of Civil Service
Employee Benefits Division
P.O. Box 1068
Schenectady, New York 12301-1068 2017 Health Insurance Choices (Actives)
www.cs.ny.gov October 2016
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 the Department of Civil Service
web site (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 web sites. If you need an auxiliary aid or service to make benefits information available to you, please
contact your Health Benefits Administrator. COBRA and Young Adult Option enrollees, contact the Employee Benefits Division.
Health Insurance Choices was printed using recycled paper and environmentally sensitive inks. Choices 2017/Actives AL1427
The New York State Department of Civil Service, which administers NYSHIP, produced this booklet
in cooperation with NYSHIP administrators 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 HMO
contracts and the Empire Plan Certificate of Insurance with Amendments are the controlling documents for
benefits available under NYSHIP.

Active Choices 2017

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Active Choices 2017

Hochgeladen von

Copyright:

Verfügbare Formate

OCTOBER 2016

Health Insurance Choices for 2017

i CHOICES 2017 ACTIVES

ACTIVES CHOICES 2017 1

Your Share of the Premium

Enrollee Pay Grade Individual Coverage Dependent Coverage

Let Your Agency Know about Changes If You Retire or

2 CHOICES 2017 ACTIVES

ACTIVES CHOICES 2017 3

4 CHOICES 2017 ACTIVES

NYSHIPS YOUNG ADULT OPTION

Young Adult Option Web Site

ACTIVES CHOICES 2017 5

6 CHOICES 2017 ACTIVES

inpatient medical/surgical speech therapy hospice benefits

ACTIVES CHOICES 2017 7

Whats New? The Empire Plan provides:

2017 Empire Plan Maximum Out-of-Pocket Limits for In-Network Services

Individual Coverage $2,500 $4,650 $7,150

Family Coverage $5,000 $9,300 $14,300

* Does not apply to Medicare-primary enrollees or the dependents of Medicare-primary enrollees.

8 CHOICES 2017 ACTIVES

ACTIVES CHOICES 2017 9

All NYSHIP HMOs cover inpatient and outpatient

10 CHOICES 2017 ACTIVES

Selecting a health insurance plan is an important How to Use the Choices

ACTIVES CHOICES 2017 11

If I am diagnosed with a serious illness, can I see a physician or go to a

12 CHOICES 2017 ACTIVES

Can I use the hospital of my choice?

Network hospital inpatient: Paid-in-full hospitalization benefits.

Network hospital outpatient and emergency care: Subject to network copayments.

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

1 Diabeticshoes have an annual maximum benefit of $500.

ACTIVES CHOICES 2017 13

14 CHOICES 2017 ACTIVES

ACTIVES CHOICES 2017 15

The Empire Plan

of Western New York*

059 Independent Health*

066 Blue Choice*

of Western New York*

059 Independent Health*

066 Blue Choice*

18 CHOICES 2017 ACTIVES

ACTIVES CHOICES 2017 19

20 CHOICES 2017 ACTIVES

ACTIVES CHOICES 2017 21

Plan toll free at 1-877-7-NYSHIP (1-877-769-7447), (single-source brand-name drugs/devices) do not

22 CHOICES 2017 ACTIVES

applicable mail service copayment is charged. To Prescription Drug Program

ACTIVES CHOICES 2017 23

24 CHOICES 2017 ACTIVES

Contraceptive Drugs and Devices No copayment for certain Basic Medical3

ACTIVES CHOICES 2017

26 CHOICES 2017 ACTIVES

24-hour NurseLineSM for health information and support at 1-877-7-NYSHIP (1-877-769-7447).

Diabetes education centers for enrollees who have a diagnosis of diabetes.

ACTIVES CHOICES 2017

28 CHOICES 2017 ACTIVES

ACTIVES CHOICES 2017 29

30 CHOICES 2017 ACTIVES

ACTIVES CHOICES 2017 31

Urgent Care Facility $25 per visit Skilled Nursing Facility