Read and Savethis Report for importantinformation about benefitchanges.

In This Report1-3 Mental Health and

Substance AbuseProgram

1, 4-5 Flexible Formulary

6-7 Benefit Changes

Special SectionNYSHIP GeneralInformation Book andEmpire Plan CertificateAmendments

8 Benefit ManagementProgram; NYSHIPChanges

9 2009 CopaymentChanges; Annual Notice

10 Participating Providers;Reminders

11 Empire Plan Carriers and Programs

12 Dependent EligibilityProject; Waiver of Out-of-Pocket Costs

JANUARY 2009

New York State Health Insurance Program (NYSHIP) For Active Employees, Retirees, Vestees and Dependent Survivors, And for their Dependents enrolled through Participating Agencies with Empire Plan Benefits

Flexible Formulary continued on page 4

Mental Health and Substance AbuseProgram continued on page 2

The Empire PlanMental Health and Substance Abuse ProgramNew Insurer and AdministratorEffective January 1, 2009,UnitedHealthcare Insurance Company of New York (UHICNY) insures andOptumHealth Behavioral Solutions(OptumHealth) administers The EmpirePlan Mental Health and Substance Abuse(MHSA) Program. The former insurer/administrator, GHI/ValueOptions, willassist with the transition. Although yourbenefits are not changing, there may bedifferences in the provider network.

OptumHealth has a large nationalprovider network and also is activelyrecruiting additional providers who

currently treat a high volume of EmpirePlan enrollees. To check if your provider is in the OptumHealth network, you cancall 1-877-7-NYSHIP (1-877-769-7447) and select the 2009 MHSA option forOptumHealth. You may also visitwww.cs.state.ny.us to search theOptumHealth provider network online.At the home page click on “BenefitPrograms” and follow the instructions toaccess NYSHIP Online. Select “Find aProvider” and scroll down toOptumHealth. The network lists will beupdated regularly as providers are added.

Effective January 1, 2009, your benefitsunder The Empire Plan Prescription DrugProgram are based on a flexible formulary.The 2009 Empire Plan Flexible Formularydrug list provides enrollees and the Planwith the best value in prescription drugspending. This is accomplished by:

• excluding coverage for a small numberof drugs if a therapeutic equivalent orover-the-counter drug is available.

• assigning a slightly higher copayment,than generic drugs for preferredbrand-name drugs that provide thebest value to The Empire Plan and

• allocating the highest copayment tonon-preferred brand-name drugs thatprovide little, if any, clinical advantageover existing generic or preferredbrand-name drugs.

Empire Plan Adopts Flexible Formulary for 2009

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2 EPR-PA-09-01

If your provider is not currently in theOptumHealth network, you maynominate your provider by calling theNYSHIP toll free number and selectingthe 2009 MHSA option.

Transition BenefitsTo help ensure that Empire Plan enrollees in outpatient treatment have access tonetwork benefits throughout thistransition, a 90-day transition of carebenefit will be available for care receivedthrough March 31, 2009. The transition ofcare benefit also applies to alternate levelsof care including partial hospitalization,intensive outpatient treatment and grouphome. If you or your dependent receivedoutpatient care under the MHSA Programon or after July 1, 2008, you are eligible for network benefits with the samepractitioner(s) through March 31, 2009regardless of whether the provider is inthe OptumHealth network. If you havereceived MHSA services from a MHSApractitioner since July 1, 2008, you shouldhave received a letter prior to the end of theyear with additional information about thischange and how to get more informationabout transition of care benefits.

If you or your dependents were receivingcare at a 24-hour facility or program forinpatient or residential treatment onDecember 31, 2008 and remainedconfined on or after January 1, 2009, the care will continue to be managed and paid for by ValueOptions/GHI until you are discharged to a lower levelof treatment.

Empire Plan Toll-Free NumberIf you seek services for 2009 or have any questions about transition, call 1-877-7-NYSHIP and select the 2009MHSA option.

When calling the toll free NYSHIP number,please listen carefully as options willchange. You will be able to reach bothOptumHealth and ValueOptions for aperiod of time. Clinical Referral Lineservices will be provided by OptumHealthand continue to be available 24 hours aday/7 days a week.

Mental Health and Substance Abuse Program continued from page 1

The Empire Plan Mental Health Management Program in 2009What’s New• MHSA Insurer:

UnitedHealthcare Insurance Company of New York (UHICNY)

• MHSA Administrator: OptumHealth Behavioral Solutions (OptumHealth)

• MHSA Network: visit www.cs.state.ny.us to find network providersNote: MHSA practitioners and facilities listed in the 2008 Empire PlanParticipating Directory are no longer correct. Please call OptumHealth or visit the web site to locate network providers.

• OptumHealth web site accessible through the Department of Civil Serviceweb site at www.cs.state.ny.us

• Claims/General Correspondence Address:OptumHealth Behavioral SolutionsP.O. Box 5190Kingston, NY 12402-5190

• Appeal Address:OptumHealth Behavioral Solutions Attn: BH Appeals Dept.900 Watervliet Shaker RoadSuite 103Albany, NY 12205-1002

• TTY Phone Number: 1-800-855-2881

What’s the Same• MHSA Program

• Empire Plan ID card

• 1-800-7-NYSHIP phone number; however there will be prompts for 2008 and 2009 benefit questions. Select the 2009 prompt to contactOptumHealth, select the 2008 prompt to contact ValueOptions.

Non-Network Inpatient Care, Partial Hospitalization, IntensiveOutpatient Program, Day Treatment, 23-hour Extended Bed and 72-Hour Crisis Bed: 90% of Billed Charges (EMPIRE PLAN AT AGLANCE CORRECTION)The Empire Plan pays up to 90 percent of billed charges for covered acuteinpatient mental health care in an approved hospital or an approved facility.You pay the remaining 10 percent until you reach an inpatient coinsurancemaximum of $1,500 for you, the enrollee, $1,500 for your enrolledspouse/domestic partner and $1,500 for all enrolled dependent childrencombined. The Empire Plan then pays 100 percent of billed charges forcovered services. This benefit is not subject to a deductible.

Each coinsurance maximum is applied as follows: You pay the first $500 ofcoinsurance, after which you will be reimbursed for the next $500 ofcoinsurance, upon written request of the enrollee, then you pay the final$500 of coinsurance.

This article also corrects the paragraph explaining Non-NetworkCoverage for Approved Facilities Under Mental Health Benefits on page11 of your Empire Plan At A Glance.

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Questions and AnswersAbout Mental Health and Substance Abuse Transition

What is the transition of care benefit?

The transition of care benefit allows you to continue to receive network benefits even if yourprovider has not joined the OptumHealth network as of January 1, 2009. All levels of care (see page 1)are covered under the transition of care benefit.

How do I access my transition of care benefit?

You do not need to call or complete any forms to access the transition of care benefit. If you receivednetwork benefits between July 1, 2008 and December31, 2008, you will automatically be given the transitionof care benefit through March 31, 2009, for servicesreceived from the same provider, even if that provideris not in the OptumHealth network. Please note thatthese benefits apply to covered services receivedbetween January 1, 2009 through March 31, 2009.

If I already have certification from ValueOptions and will be using the transition of care benefit, will my certification from ValueOptions transferover, or do I need to call OptumHealth?

You do not have to call OptumHealth, but you may call if you have questions 24 hours a day, 7 days a week. Call the NYSHIP toll-free number below,press Option 3 and select the 2009 MHSA option.

How do I find out if my provider is in theOptumHealth network?

Visit www.cs.state.ny.us or call the NYSHIP toll-freenumber below, press option 3 and select the 2009 MHSAoption for OptumHealth. Provider network informationwill be updated regularly.

I just checked the web site and my provider is not currently in the OptumHealth network. What are my options?

The transition of care benefit allows you to receivenetwork benefits, even if the provider you were seeingin 2008 is not part of the OptumHealth network. Whenthe transition period ends on March 31, 2009, you mustuse an OptumHealth network provider to receive thehighest level of benefits. You may call OptumHealth atany time to access network benefits. If you continuetreatment with your provider after March 31, 2009 andyour provider is not part of the OptumHealth network,your treatment will be covered under the non-networkbenefit, and you will have higher out-of-pocket costs.

How can my provider become part of theOptumHealth network?

If your provider is not currently in the OptumHealthnetwork, you may nominate your provider by callingthe NYSHIP toll-free number below, pressing Option 3and selecting the 2009 MHSA option. Or, your providermay call OptumHealth directly at the same number.

What if I need treatment after the beginning of the year and I am not eligible for the transition ofcare benefit?

To find a network provider for treatment on or after January 1, 2009, call the NYSHIP toll-freenumber below, press Option 3 and select the 2009 MHSA option for OptumHealth.

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Instant Rebate for Omeprazole(generic Prilosec)For a limited time only, The Empire PlanPrescription Drug Program will offer aninstant rebate of your full copaymentfor omeprazole, the generic version of Prilosec (the original “purple pill”).This medication is a proton pumpinhibitor used in the treatment ofpeptic ulcers, gastroesophageal refluxdisease (GERD) and othergastrointestinal symptoms.

The instant rebate will apply to allomeprazole prescriptions filled atparticipating retail pharmacies or at a mail service pharmacy betweenJanuary 1 and April 30, 2009. To receiveyour rebate (zero copayment), simplypresent your prescription to your retail pharmacy or send it to the mailservice pharmacy. You do not have toenroll, or pre-qualify for the zerocopayment. After April 30, 2009, you willpay the applicable generic copayment($5 or $10) for subsequent refills. If youhave questions about this rebate oryour drug benefit, call The Empire Plan Prescription Drug Program at 1-877-7-NYSHIP (1-877-769-7447) and choose option 4.

The main features of The Empire Plan2009 Flexible Formulary are:

• Copayment levels for generic drugs:Generic drugs are placed at the lowestcopayment level (for example, $5 for a30-day supply at a participating retailpharmacy).

• Coverage for brand-name drugs:Certain brand-name drugs will beexcluded from coverage. If a brand-name drug is excluded, therapeuticbrand-name and/or genericalternatives will be covered.

• Copayment levels for brand-namedrugs: Covered brand-name drugs are classified as preferred or non-preferred and are available at eitherthe second or third copayment levels(for example, preferred brand-namedrugs have a $15 copayment and non-preferred brand-name drugs have a$40 copayment for a 30-day supply ata participating retail pharmacy).

The following drugs will be excludedfrom coverage under the 2009 EmpirePlan Flexible Formulary drug list: Adoxa,Caduet, Coreg CR, Doryx, Genotropin1,Humatrope2, Kapidex, Nexium,Norditropin3, Omnitrope, PrevacidCapsules, Testim, Treximet and Veramyst.

As a reminder, the Plan reviews the drug listonce a year so in addition to theseexclusions, enrollees may notice otherbrand-name drugs that have a differentcopayment level as of January 1, 2009. Ifyou have been taking one or more of thesedrugs, you should have already received aletter informing you of this change. Youmay want to discuss an alternativemedication with your doctor that will resultin your paying a lower copayment. Seeyour 2009 Empire Plan At A Glance for aprinted copy of the Flexible Formularydrug list or visit the Department of CivilService web site at www.cs.state.ny.us,select Benefit Programs, then NYSHIPOnline and choose your group, ifprompted. Alphabetic and therapeuticclass versions of the 2009 FlexibleFormulary are available under the UsingYour Benefits button.

Flexible Formulary continued from page 1

1 Excluded, except for treatment of growth failuredue to Prader-Willi syndrome or Small forGestational Age. Prior authorization is required.

2 Excluded, except for treatment of growth failure dueto SHOX deficiency. Prior authorization is required.

3 Excluded, except for treatment of short statureassociated with Noonan syndrome or small forGestational Age. Prior authorization is required.

This voluntary program allows you toreduce the out-of-pocket cost of selectcovered prescription drugs you take on aregular basis by:

• allowing your physician to write aprescription for twice the dosage ofyour medication and half the numberof tablets (see Example).

• having you split the pills in half usingthe free pill splitter that The EmpirePlan will provide and

• instructing the participating retailpharmacy or the mail service pharmacyto automatically reduce yourcopayment to half the normal charge:

Example

Old Prescription:..................Lipitor 10 mg

Quantity: .......................................30 tablets

Dosage: .....Take 1 tablet every morning

Copayment...............................................$15

New Prescription:................Lipitor 20 mg

Quantity: .......................................15 tablets

Dosage: ....Take ½ tablet every morning

Copayment ...........................................$7.50

For a listing of drugs eligible for the HalfTablet Program, visit the Department ofCivil Service web site at www.cs.state.ny.us.Select Benefit Programs on the homepage, then NYSHIP Online and chooseyour group, if prompted. Choose UsingYour Benefits then Empire Plan Providers,Pharmacies and Services, scroll down toMedco and select Empire PlanPrescription Drug Half Tablet Program.

Splitting Tablets is Easy

Using a tablet splitter makes splitting yourmedication easy. Never attempt to splittablets with anything other than a devicedesigned specifically for that purpose. Not

all medications are appropriate for tabletsplitting. Consult your doctor beforesplitting any prescribed medication.

Order Free Tablet Splitter

The Empire Plan willoffer a free tabletsplitter to eachenrollee who iscurrently prescribed adrug that is covered as part of the Half Tablet Program. If you are on a medication eligible for the half-tablet program, you will receive awelcome letter with details on how toorder your free tablet splitter.

The Empire Plan Half Tablet Program Lowers Your Prescription Cost

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Questions and AnswersAbout The Empire Plan Flexible Formulary

Why are some medications being excluded?

Certain drugs are being excluded under The EmpirePlan Prescription Drug Program so that we cancontinue to provide the best value in prescription drugcoverage to all enrollees under the Plan. Whenever aprescription drug is excluded, therapeutic brandand/or generic equivalents will be covered.

Why is Nexium excluded from the 2009 Empire Plan Flexible Formulary?

Independent studies conducted by Consumer Reports,the Oregon Health Resources Commission, and AARP, to name a few, have found that there is little clinicaldifference in efficacy or adverse effects in the class ofprescription drugs that Nexium belongs to - protonpump inhibitors (PPIs). There is, however, a significantdifference in the cost. The 2009 Empire Plan FlexibleFormulary continues to cover generic and other preferredbrand-name PPIs that provide the best value to the Plan.

How do I qualify for the four-month instant rebate ofthe copay for the drug omeprazole (for PPI utilizers)?

All prescriptions filled for omeprazole betweenJanuary 1, 2009 and April 30, 2009 will automaticallyreturn a zero copayment. You do not have to enroll, or pre-qualify for the zero copayment.

How will I know if my drug is excluded from the2009 Empire Plan Flexible Formulary?

Letters were mailed in late November to all enrolleeswho took an excluded medication in the previous four months to notify them of the change and offercovered equivalents. The listing of drug exclusions isincluded on the last page of the Flexible Formularydrug list. The list was sent to enrollees as part of the2009 Empire Plan At A Glance and can be requestedthrough customer service by calling 1-877-7-NYSHIP(1-877-769-7447) and choosing Option 4. It is alsoavailable on the New York State Department of Civil Service web site at www.cs.state.ny.us, and was mailed to all Empire Plan Participating Physiciansand enrollees.

How will my local pharmacist know my drug isexcluded?

Your local participating pharmacist will receive amessage when your claim is processed that will advisethat the drug is not covered under The Empire Plan. Ifyou choose to fill the prescription, you will be responsiblefor paying the full cost of the drug; The Empire Plan willnot reimburse you for any portion of the cost.

What will happen if I send a new prescription or request a refill from Medco by Mail for anexcluded drug?

If you call in a refill of an excluded drug through a mailservice pharmacy, the customer service representative orinteractive voice response system will advise you that thedrug is excluded, and your order will be cancelled. If youmail in a refill order, you will receive a letter indicatingyour drug is no longer covered under the Plan. If you mailin a new prescription for an excluded drug, the mailservice pharmacy will return the prescription along with aletter advising that the drug is excluded from Empire Plancoverage and can no longer be dispensed.

How will my physician know that my drug isexcluded?

The 2009 Flexible Formulary drug list was sent to allparticipating physicians in The Empire Plan Network.Additionally, if your physician utilizes an online methodof prescribing known as EPrescribing, a message willbe displayed indicating that the drug is not covered.

Where can I find lower cost alternatives to the drug I am taking?

Suggested generic and/or preferred brand-name drugequivalents are listed on the last page of the FlexibleFormulary drug list. We recommend that you talk withyour physician to identify which medication isappropriate to treat your condition.

How do I change to one of the preferred medicationson The Empire Plan Flexible Formulary? Will I need anew prescription?

Yes, you will need a new prescription. If you are almostout of medication, you can request that your retailpharmacist call your physician for a new prescription of a generic or preferred brand-name drug.

If you use a mail service pharmacy, the mail servicepharmacy will assist you with obtaining a newprescription. Please call customer service at 1-877-7-NYSHIP (1-877-769-7447) and choose Option 4 for assistance.

Can I appeal a drug exclusion or level placement?

No. Drug exclusions and level placements are acomponent of your Benefit Plan Design and cannot be appealed.

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The Empire Plan Medical/SurgicalBenefits Program$30 Copayment for Non-HospitalOutpatient Surgical Locations

Beginning January 1, 2009, you pay thefirst $30 in charges (copayment) for eachvisit to an outpatient surgical locationthat has an agreement in effect withUnitedHealthcare.

The $30 copayment covers your electivesurgery and anesthesiology, radiology and laboratory tests performed on the day of the surgery at the same outpatientsurgical location.

Herpes Zoster Vaccine for Shingles

Effective January 1, 2009, the HerpesZoster Vaccine used to prevent shingles is covered as an adult immunizationunder the Participating Provider Programfor individuals age 55 or over. Sinceshingles usually occurs in the seniorpopulation, this coverage is consistentwith established clinical guidelines. You pay only the office visit copaymentwhen you receive the Herpes Zostervaccination from a Participating Provider.There is no non-network benefit.

Prosthetic Wig Benefit

Effective January 1, 2009, wigs will becovered under the Basic Medical Programwhen hair loss is due to an acute orchronic condition that leads to hair lossincluding, but not limited to:

• Disease of endocrine glands such asAddison’s disease and ovarian genesis

• Generalized disease affecting hairfollicles such as systemic lupus andmyotonic dystrophy

• Systemic poisons such as Thallium,Methotrexate and prolonged use ofanticoagulants

• Local injury to scalp such as burns,radiation therapy, chemotherapytreatment and neurosurgery

Excluded from coverage is male andfemale pattern baldness.

There is a lifetime maximum benefit of$1,500 per individual regardless of thenumber of wigs purchased. Benefits arenot subject to the Basic Medical deductibleor coinsurance. Claims submitted for theprosthetic wig benefit must includedocumentation from the treatingphysician that states that the individualhas a diagnosis for a covered condition.

Participating Diabetes Education Centers

Diabetes education can be an importantpart of a treatment plan for diabetes.Diabetes educators provide information on nutrition and lifestyle improvementthat can help diabetics better managetheir disease. The Empire Plan networknow includes Diabetic Education Centersthat are accredited by the AmericanDiabetes Association EducationRecognition Program. If you have adiagnosis of diabetes, your visits to anetwork center for self-managementcounseling are covered and you pay onlyan office visit copayment for eachcovered visit. Covered services at a non-network diabetes education center areconsidered under the Basic MedicalProgram subject to deductible andcoinsurance.

To find an Empire Plan participatingdiabetes education center, call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and chooseUnitedHealthcare. Or, go to the New YorkState Department of Civil Service web site(www.cs.state.ny.us), click on BenefitPrograms and then NYSHIP Online. Selectyour group if prompted, click on Find aProvider and then Medical and SurgicalProviders under UnitedHealthcare.

Diabetic Shoes

Effective January 1, 2009, one pair of custom molded or depth shoes per calendar year are a covered expense under The Empire Plan if:

• You have a diagnosis of diabetes and diabetic foot disease;

• Diabetic shoes have been prescribed by your provider; and

• The shoes are fitted and furnished by a qualified perdorthist, orthotist,prosthetist or podiatrist. Shoes orderedby mail or from the internet are noteligible for benefits.

When you use an HCAP-approved providerfor medically necessary diabetic shoes, you receive a paid-in-full benefit up to anannual maximum benefit of $500. Toensure that you receive the maximumbenefit, you must make a pre-notificationcall to the Home Care Advocacy Program(HCAP). You must call The Empire Plan tollfree at 1-877-7-NYSHIP (1-877-769-7447),choose UnitedHealthcare and then theBenefits Management Program. HCAP willassist you in making arrangements toreceive network benefits for diabetic shoes.

If you do not receive medically necessarydiabetic shoes from an HCAP-approvedprovider, benefits will be consideredunder the Basic Medical Program subjectto the annual deductible with anyremaining covered charges paid at 75% ofthe network allowance with a maximumannual benefit of $500.

Centers of Excellence Programs for Transplants and CancerEffective January 1, 2009, when you use a Center of Excellence for Transplants that has been pre-authorized by EmpireBlueCross BlueShield or a Center ofExcellence for Cancer that has been pre-authorized by UnitedHealthcare andthe Center of Excellence is more than 100miles from the enrollee’s residence (200miles for airfare), The Empire Planprovides travel, meals and one lodging per day for the patient and one travelcompanion. The Empire Plan willreimburse for meals and lodging based on the United States General ServicesAdministration (GSA) per diem rate andautomobile mileage (personal or rentalcar) based on the Internal RevenueService medical rate. The following are the only additional travel expenses thatare reimbursable: economy class airfare,train fare, taxi fare, parking, tolls andshuttle or bus fare from your lodging to

Empire Plan Benefit Changes Effective January 1, 2009

Benefits Changes continued on page 7

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the Center of Excellence. To find thecurrent per diem rates for lodging andmeals, visit the United States GeneralServices Administration web site atwww.gsa.gov and look under TravelResources. Travel and lodging benefits areavailable as long as the patient remainsenrolled and receiving benefits under theCenters of Excellence programs forTransplants or Cancer. The $10,000lifetime maximum for travel, meals andlodging for the Centers of Excellence forCancer Program has been eliminated.

Kidney Resource Services ProgramEffective January 1, 2009, The Empire Planwill offer a Kidney Resource ServicesProgram to its enrollees when The EmpirePlan is your primary health insurancecoverage. If you or your dependents havebeen diagnosed with Chronic KidneyDisease (CKD), you may be invited toparticipate in this disease managementprogram. Participation is voluntary, free ofcharge and confidential.

If you agree to participate, you will receive information to help you betterunderstand your condition. You will beoffered educational materials and otherservices that may help to improve themanagement of your kidney disease. Youmay also be contacted by a RegisteredNurse in conjunction with this program.

This program works in partnership with your physician to achieve the bestpossible health outcomes.

If you have questions or would like moreinformation, call The Empire Plan toll freeat 1-877-7-NYSHIP (1-877-769-7447) andchoose the option for The Empire PlanNurseLine.

2009 Annual Deductible andCoinsurance Maximum for BasicMedical and Non-Network MentalHealth Practitioner Services Annual Deductible: $363 Coinsurance Maximum: $1,000

For calendar year 2009, The Empire Planannual deductible for services performedand supplies prescribed by non-participating or non-network providers is $363 for you, $363 for your enrolledspouse/domestic partner and $363 for allcovered dependent children combined.

You must meet the deductible beforebenefits are paid for your claims. The annualdeductible for the Basic Medical Programand the non-network portion of the MentalHealth Program cannot be combined witheach other or with the Managed PhysicalMedicine Program annual deductible fornon-network services.

Effective January 1, 2009, there is aseparate annual coinsurance maximum (out-of-pocket expense) of $1,000 for you, $1,000 for your enrolled spouse,domestic partner and $1,000 for allcovered dependent children combined in 2009. After each coinsurance maximumis reached, you will be reimbursed 100percent of the reasonable and customaryamount, or 100 percent of the billedamount, whichever is less, for coveredservices. You will still be responsible forany charges above the reasonable andcustomary amount and for any penaltiesunder the benefits management programs.

CAM Program DiscontinuedThe Empire Plan Complementary andAlternative Medicine Program (CAM) wasdiscontinued effective January 1, 2009 in accordance with negotiated contractsand agreements with unsettled and non-negotiating groups.

Benefits Changes continued from page 6

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NYSHIP Changes Effective January 1, 2009Leaving School Before GraduationBeginning January 1, 2009, an enrolled, full-time student dependent age 21 orolder who completes a semester willcontinue to be covered under NYSHIPuntil the last day of the third monthfollowing the month in which thedependent completes the semesterunless the dependent otherwise losesNYSHIP eligibility. For example, if thedependent child completes the Springsemester in May, the last day of coveragewould be August 31. However, if thedependent reaches age 25 before August 31, coverage ends on thedependent’s birthday. This coverageextension applies to each semester thedependent child completes, including thesemester in which the requirements forgraduation are completed. A semester isconsidered to be completed if thestudent attends classes through the lastrequired date of attendance for thesemester, even if a passing grade is notachieved for coursework.

If a dependent student age 21 or olderleaves school prior to the successfulcompletion of a semester and proof ofattendance during the semester isprovided, coverage ends on the last dayof the month in which the dependentattended school or the end of the thirdmonth following the month that the last semester was completed, whicheveris later. If the required proof is notprovided, coverage will end on the firstday of the incomplete semester or threemonths after the previously completedsemester whichever is later.

Generally a dependent child over the age of 21 must be a full-time student atan accredited secondary or preparatoryschool, college or other educationalinstitution to be eligible for NYSHIPcoverage. Refer to your GeneralInformation Book for additional eligibilityinformation for dependent children whoare disabled, on medical leave or havemilitary service.

Additional Imaging ProceduresRequire Prospective Procedure Review(PPR) Effective January 1, 2009You must call The Empire Plan BenefitsManagement Program for ProspectiveProcedure Review of the followingoutpatient imaging procedures whenperformed as an elective (scheduled)procedure:

• Magnetic Resonance Imaging(MRI)/Magnetic ResonanceAngiography (MRA)

• Computed Tomography (CT)

• Positron Emission Tomography (PET) Scans

• Nuclear Medicine DiagnosticProcedures

Call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447), and select UnitedHealthcare, thenBenefits Management to reach the Care Coordination Unit.

Should you opt to have one of theseprocedures before the review is completedor if you do not call the BenefitsManagement Program before having itand UnitedHealthcare determines that theprocedure was performed on a scheduled(non-emergency) basis and that theprocedure was medically necessary, youare responsible for paying the lesser of 50percent of the scheduled amounts relatedto the procedure or $250, plus yourcopayment, under the ParticipatingProvider Program.

Under the Basic Medical Program, you areliable for the lesser of 50 percent of thereasonable and customary chargesrelated to the procedure or $250. Inaddition, you must meet your BasicMedical annual deductible and you mustpay the coinsurance and any providercharges above the reasonable andcustomary amount.

If UnitedHealthcare determines that theprocedure was not medically necessary,you will be responsible for the full cost ofthe procedure.

Benefits Management Program

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New Copay D Benefit CardsIn early December 2008, PA enrollees were mailed newEmpire Plan benefit cards with "Copay D" (see graphic) on them. These new identification cards were necessarydue to the January 1, 2009 benefit changes described inthis Report and they replace your "Copay A" card(s). Asinstructed on the card carrier, you and your enrolleddependents should use the new cards for any services sought on and after January 1, 2009. You should have also received your January 2009 Empire Plan At AGlance in the mail at your home in December, which contained new pocket/walletcopayment cards that specified the changed copayment amounts. See your agencyHealth Benefits Administrator (HBA) if you did not receive benefit cards, need to orderan additional or replacement card or did not receive the At A Glance publication.

JAMES EMPIRE PLAN ENROLLEE

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Copay Code DCopaymentsSee pages 199 and 200 of yourEmpire Plan CertificateAmendments for a complete list of your 2009 copayments.

Annual Notice of Mastectomyand Reconstructive SurgeryBenefitsThe Empire Plan covers inpatienthospital care for lymph nodedissection, lumpectomy andmastectomy for treatment ofbreast cancer for as long as thephysician and patient determinehospitalization is medicallynecessary. The Plan covers allstages of reconstructive breastsurgery following mastectomy,including surgery of the otherbreast to produce a symmetricalappearance. The Plan also coverstreatment for complications of mastectomy, includinglymphedema. Prostheses andmastectomy bras are covered.

Call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447)and select UnitedHealthcare ifyou have questions about yourcoverage for implants, breastforms or other prosthesesrelated to breast cancertreatment.

Empire Plan BenefitsManagement Programrequirements apply. See yourEmpire Plan Certificate andEmpire Plan Reports.

2009 Copayment Changes

Prescription Drug ProgramNon-Preferred Brand-Name Drug Copayments

Supply Dispensed Copayment

Up to a 30-day supply from a participatingretail pharmacy or through the mail service $40

A 31- to 90-day supply through the mail service $65

A 31- to 90-day supply from a participatingretail pharmacy

$70

The following copayment changes are effective January 1 for the specified programsand services. It is your responsibility as a patient to be aware of copayments due at thetime services are rendered.

Participating Provider Program $20 Copayment—Office Visit/Office Surgery, Radiology/Diagnostic Laboratory Tests,Free-Standing Cardiac Rehabilitation Center Visit, Urgent Care Visit

$30 Copayment—Outpatient Surgery at Free-Standing Outpatient Surgery Center

Chiropractic Treatment or Physical Therapy Services (Managed Physical MedicineProgram)

$20 Copayment—Office Visit, Radiology, Diagnostic Laboratory Tests

Hospital Services (Hospital Program) $20 Copayment—Outpatient Physical Therapy at Network Hospital or Hospital OwnedExtension Clinic

Mental Health and Substance Abuse Program $20 Copayment—Visit to Outpatient Substance Abuse Treatment Program, Visit to Mental Health Practitioner for Outpatient Mental Health care

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The Empire Plan is a unique program that allows you to receive medical/surgical care from participating providers or from non-participating providers. By choosing a participating provider, you receive covered services at little or no cost and you don’t have tofile a claim. For certain services, you must call before you receive services. Participating providers are providers who have anagreement in effect under The Empire Plan. They have agreed to bill UnitedHealthcare and to accept your copayment, for servicessubject to a copayment, plus payment directly from the Plan as payment-in-full for covered services.

Participating Provider Program

The Empire Plan Participating ProviderProgram offers a network of over 175,000physicians and other providers locatedthroughout New York State and in manyother states as well. You have the freedomto choose any participating providerwithout a referral. There is, however, noguarantee that a participating providerwill always be available to you.

Providers in the network include: doctors,speech therapists, speech-languagepathologists, audiologists, podiatrists,laboratories, outpatient surgical locations,urgent care centers, freestanding cardiacrehabilitation centers and Centers ofExcellence. Certified nurse midwives may also be available throughparticipating doctors. Always ask yourprovider if he or she participates beforeyou receive services.

When you use a participating provider,you pay only the applicable copayment.

Ask for a Participating Provider

The Empire Plan does not require that aparticipating provider refer you to aparticipating laboratory, radiologist,specialist or center. It is yourresponsibility to request a participatingprovider for other services. Explain toyour doctor that your out-of-pocketexpenses are usually higher if you don’tuse a participating lab or if a non-participating radiologist reads your X-ray.

Please be aware, too, that providers withmultiple locations may not be Empire Planparticipating providers in all locations.

It is your responsibility to determinewhether a provider is an Empire Planprovider. In Arizona, Connecticut, Florida,New Jersey, North Carolina, SouthCarolina, Washington D.C., and statesadjacent to D.C., ask if the physician is

part of UnitedHealthcare’s OptionsPreferred Provider Organization (PPO). Inall other states including New York, andfor providers other than physicians in the above states, ask if the providerparticipates in The Empire Plan.

Participating Provider Directory

The most up-to-dateparticipating providerinformation is availableon the Department ofCivil Service web siteat ww.cs.state.ny.us.Click on BenefitPrograms and then onNYSHIP Online. Selectyour group, if prompted, and then clickon Find A Provider. If you need a printedcopy of the 2008 Empire Plan ParticipatingProvider Directory, see your agency HealthBenefits Administrator. But rememberthat the MHSA listings are not correct(see page 2).

Choosing a Participating Provider

State of New York Department of Civil Service Employee Benefits Division

Albany, New York 12239518-457-5754 (Albany area)

1-800-833-4344 (U.S., Canada, Puerto Rico, Virgin Islands)

www.cs.state.ny.us

The Empire Plan Report is published by theEmployee Benefits Division of the State ofNew York Department of Civil Service. TheEmployee Benefits Division administers theNew York State Health Insurance Program(NYSHIP). NYSHIP provides your healthinsurance benefits through The Empire Plan.

RemindersThe Empire Plan At A Glance andCopayment CardsThe 2009 Empire Plan At A Glance alongwith 2009 Empire Plan Copayment Cardsand the 2009 Preferred Drug List weresent to you in a separate mailing earlierthis year. The Empire Plan At A Glanceoffers a brief description of your EmpirePlan benefits; the Copayment Cardsprovide a handy reference for coveragecosts. If you need more cards, or anothercopy of the At A Glance, ask your agencyHealth Benefits Administrator.

Reimbursement of the Medicare Part B Income-Related MonthlyAdjustment Amount (IRMAA) forMedicare-Primary EnrolleesMedicare law requires some people to pay a higher premium for their MedicarePart B coverage based on their income. If you and/or any of your enrolled

dependents are Medicare-primary andreceived a letter from the Social SecurityAdministration (SSA) requiring thepayment of an income-related monthlyadjustment amount (IRMAA) in addition tothe standard 2008 Medicare Part Bpremium ($96.40) for 2008, you are eligibleto be reimbursed for this additionalpremium by your agency. Note: If your2006 adjusted gross income was lessthan or equal to $82,000 ($164,000 ifyou filed taxes as married filing jointly)you are NOT eligible for any additionalreimbursement this year.

To claim the additional IRMAAreimbursement, eligible enrollees arerequired to apply for and document theamount paid in excess of the standardpremium. Contact your agency HealthBenefits Administrator for information onhow to apply, a list of the documentsrequired or questions on IRMAA.

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The Empire Plan Carriers and ProgramsTo reach any of The Empire Plan carriers, call toll free 1-877-7-NYSHIP (1-877-769-7447).The one number is your first step to Empire Plan information. Check the list below to know which carrier to select. When you call 1-877-7-NYSHIP, listen carefully to your choices and press or say your selection at any time during the message.Follow the instructions and you’ll automatically be connected to the appropriate carrier.

The Empire Plan Hospital Benefits Program Empire BlueCross BlueShield, New York State Service Center, P.O. Box 1407, ChurchStreet Station, New York, NY 10008-1407. Web site: www.empireblue.com. Call for information regarding hospital and related services.

Benefits Management Program for Pre-Admission Certification You must call Empire BlueCross BlueShield before amaternity or scheduled hospital admission, within 48 hours after an emergency or urgent hospital admission and beforeadmission or transfer to a skilled nursing facility (includes rehabilitation facilities).

Centers of Excellence for Transplants Program You must call Empire BlueCross BlueShield before a hospital admissionfor the following transplant surgeries: bone marrow, peripheral stem cell, cord blood stem cell, heart, kidney, liver, lung andsimultaneous kidney-pancreas. Call for information about Centers of Excellence.

The Empire Plan Medical/Surgical Benefits Program UnitedHealthcare Insurance Company of New York, P.O. Box 1600,Kingston, NY 12402-1600. Web site: www.myuhc.com. Call for information on benefits under Participating Provider, Basic MedicalProvider Discount and Basic Medical Programs, predetermination of benefits, claims and participating providers.

Managed Physical Medicine Program/MPN Call UnitedHealthcare for information on benefits and to find MPN network providersfor chiropractic treatment and physical therapy. If you do not use MPN network providers, you will receive a significantly lower levelof benefits.

Benefits Management Program for Prospective Procedure Review of MRI, MRA, CT, PET Scans and Nuclear Medicinetests You must call UnitedHealthcare before having an elective (scheduled) procedure or nuclear medicine test.

Home Care Advocacy Program (HCAP) You must call UnitedHealthcare to arrange for paid-in-full home care services,enteral formulas, diabetic shoes and/or durable medical equipment/supplies. If you do not follow HCAP requirements, youwill receive a significantly lower level of benefits. You must also call UnitedHealthcare for HCAP approval of an externalmastectomy prosthesis costing $1,000 or more.

Infertility Benefits You must call UnitedHealthcare for prior authorization for the following Qualified Procedures,regardless of provider: Assisted Reproductive Technology (ART) procedures including in vitro fertilization and embryoplacement, Gamete Intra-Fallopian Transfer (GIFT), Zygote Intra-Fallopian Transfer (ZIFT), Intracytoplasmic Sperm Injection(ICSI) for the treatment of male infertility, assisted hatching and microsurgical sperm aspiration and extraction procedures;sperm, egg and/or inseminated egg procurement and processing and banking of sperm and inseminated eggs. CallUnitedHealthcare for information about infertility benefits and Centers of Excellence.

Centers of Excellence for Cancer Program You must call UnitedHealthcare to participate in The Empire Plan Centers ofExcellence for Cancer Program.

The Empire Plan Mental Health and Substance Abuse Program OptumHealth (administrator for UnitedHealthcare, P.O. Box 5190, Kingston, NY 12402-5190; Appeals - OptumHealth Behavioral Solutions, Attn: BH Appeals Dept., 900 Watervliet Shaker Road,

Suite 103, Albany, NY 12205-1002. You must call OptumHealth before beginning any non-emergency treatment for mentalhealth or substance abuse, including alcoholism. You will receive the highest level of benefits by calling and followingOptumHealth’s recommendations. In a life-threatening situation, go to the emergency room. Call within 48 hours or as soonas reasonably possible after inpatient admission.

The Empire Plan Prescription Drug Program UnitedHealthcare appeals, grievances, prior authorization documentation,general correspondence: Empire Plan Prescription Drug Program, P.O. Box 5900, Kingston, NY 12402-5900. Claim forms from retailpharmacies: Empire Plan Prescription Drug Program, P.O. Box 14711, Lexington, KY 40512. Mail Service Pharmacy: Medco, P.O. Box 6500,Cincinnati, OH 45201-6500. For the most current list of prior authorization drugs, call The Empire Plan or go to www.cs.state.ny.us.

The Empire Plan NurseLineSM Call for health information and support, 24 hours a day, seven days a week. To listen to the HealthInformation Library, enter PIN number 335 and a four-digit topic code from The Empire Plan NurseLine brochure.

Teletypewriter (TTY) numbers for callers when using a TTY device because of a hearing or speech disability:Empire BlueCross BlueShield .....................................................................................TTY only: 1-800-241-6894UnitedHealthcare ........................................................................................................TTY only: 1-888-697-9054OptumHealth ...............................................................................................................TTY only: 1-800-855-2881The Empire Plan Prescription Drug Program............................................................TTY only: 1-800-759-1089

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It is the policy of the State of New York Department of Civil Service to provide reasonable accommodation to ensure effective communication of information inbenefits publications to individuals with disabilities. These publications are also available on the Department of Civil Service web site (www.cs.state.ny.us). Clickon Benefit Programs, then NYSHIP Online for timely information that meets universal accessibility standards adopted by New York State for NYS agency websites. If you need an auxiliary aid or service to make benefits information available to you, please contact your agency Health Benefits Administrator. New YorkState and Participating Employer Retirees and COBRA Enrollees: Contact the Employee Benefits Division at 518-457-5754 (Albany area) or 1-800-833-4344 (U.S.,Canada, Puerto Rico, Virgin Islands).

EPR0-PA-Empire Plan-09-01

SAVE THIS DOCUMENT

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

PA Empire Plan Report – January 2009

This Report was printed using recycled paper and environmentally sensitive inks. PA0162

CHANGE SERVICE REQUESTED

State of New York Department of Civil ServiceEmployee Benefits DivisionP.O. Box 1068Schenectady, New York 12301-1068www.cs.state.ny.us

Please do not send mail orcorrespondence to the returnaddress. See page 10 foraddress information.!

Waiver of Out-of-Pocket Costs by Non-Participating ProvidersSome non-participating providerswrongly waive out-of-pocket payments(deductible and coinsurance) for EmpirePlan enrollees. Waiver of out-of-pocketpayments may lead to submission ofinflated claims, which under certaincircumstances may be consideredinsurance fraud. You are responsible forpayment of all out-of-pocket amounts.The level of benefits to which you areentitled is based on meeting alldeductible and coinsurance paymentsstated in your insurance certificate. Youshould discuss this issue and yourpotential out-of-pocket liability with yournon-participating provider before youreceive services. If you are aware ofprovider fraud or abuse, call The EmpirePlan at 1-877-7-NYSHIP (1-877-769-7447) and notify the applicable carrier.

NYSHIP Dependent Eligibility Verification ProjectIn 2009, the New York State HealthInsurance Program (NYSHIP) willconduct an audit of all dependentsthat have health care coveragethrough NYSHIP. If you have familycoverage you will receive a packetthat will include a list of yourdependents who are currentlyenrolled for health care coverage,along with an eligibility worksheetand a list of required documents you must provide. You must supplythe dependent documentation evenif you have previously done so. Do not submit documents now –wait for the packet to be delivered. Go to www.cs.state.ny.us/nyshipeligibilityproject/index.cfm

for information on the DependentEligibility Verification Project.Bookmark the page and visit itperiodically for the most currentinformation.

You must provide the requireddocumentation to ensure that yourenrolled dependents continue to becovered under NYSHIP. Ineligible orunverified dependents will bedropped from coverage.

The Department of Civil Service iscontracting with BUDCO, a dependentverification specialty company, toconduct the Dependent EligibilityVerification Project.

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