NEW YORK STATE HEALTH INSURANCE PROGRAM (NYSHIP)FOR NEW YORK STATE AND PARTICIPATING EMPLOYER RETIREES, VESTEES, DEPENDENT SURVIVORS And ENROLLEES covered under PREFERRED LIST PROVISIONSAnd for their enrolled Dependentsand for COBRA Enrollees with their Empire Plan Benefits

J A N U A R Y 2 0 0 9

I n T h i s R e p o r t

1&4 Flexible Formulary1- 3 Mental Health/Substance

Abuse Program4 Half-Tablet Program

NYSHIP GeneralInformation Book and Empire PlanCer tificate Amendments

Retiree Meeting Schedule

6 Benefit News; Reminders7 Empire Plan Carriers

and Programs8 Dependent Eligibility

Project; Waiver of Out-of-Pocket Costs

P L A NREPORT

SPECIALSECTIONS

SAVE THISREPORT

New Mental Health/Substance Abuse Insurerand 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 whocurrently treat a high volume of EmpirePlan enrollees. To check if your provideris 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 instructionsto access NYSHIP Online. Select “Find a Provider” and scroll down toOptumHealth. The network lists will be updated regularly as providers areadded. If your provider is not currentlyin the OptumHealth network, you maynominate your provider by calling theNYSHIP toll free number and selectingthe 2009 MHSA option.

CopaymentsSee pages 269 and 270 of your EmpirePlan Certificate Amendments for acomplete list of your 2009 copayments.

Empire Plan Prescription Drug ProgramFlexible FormularyEffective January 1, 2009, your benefitsunder The Empire Plan PrescriptionDrug Program are based on a flexibleformulary. The 2009 Empire PlanFlexible Formulary drug list providesenrollees and the Plan with the bestvalue in prescription drug spending.This is accomplished by:• excluding coverage for a small

number of drugs if a therapeuticequivalent or over-the-counter drug is available.

• assigning a slightly highercopayment, than generic drugs, forpreferred brand-name drugs thatprovide the best value to The EmpirePlan and

• allocating the highest copayment tonon-preferred brand-name drugsthat provide little, if any, clinicaladvantage over existing generic orpreferred brand-name drugs.

The main features of The Empire Plan2009 Flexible Formulary are:• Copayment levels for generic drugs:

Generic drugs are placed at thelowest copayment level (forexample, $5 for a 30-day supply at aparticipating retail pharmacy).

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

New Insurer and Administratorcontinued on page 2

Flexible Formulary continued on page 4

Transition BenefitsTo help ensure that Empire Plan enrolleesin outpatient treatment have access tonetwork benefits throughout thistransition, a 90-day transition of carebenefit is available for care receivedthrough March 31, 2009. The transition of care benefit also applies to alternatelevels of care including partialhospitalization, intensive outpatienttreatment and group home. If you oryour dependent received outpatient careunder the MHSA Program on or afterJuly 1, 2008, you are eligible for networkbenefits with the same practitioner(s)

70949_RET_EPR.qxp 3/25/09 4:19 PM Page 1

EPR-RETIREE-09-01 2

New MHSA Insurer and Administratorcontinued from page 1 What’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 visitthe web site to locate network providers.

• OptumHealth web site accessible through the Department of Civil Service website 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 contact OptumHealth, selectthe 2008 prompt to contact ValueOptions.

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.

through March 31, 2009 regardless ofwhether the provider is in theOptumHealth network. If you havereceived MHSA services from a MHSApractitioner since July 1, 2008, youshould have received a letter prior to the end of the year with additionalinformation about this change and howto get more information abouttransition of care benefits.If you or your dependents are receivingcare at a 24-hour facility or program forinpatient or residential treatment onDecember 31, 2008 and remain confinedon or after January 1, 2009, the care will continue to be managed and paid for by ValueOptions/GHI until you aredischarged to a lower level of treatment.

Empire Plan Toll-Free NumberIf you need services or if you have any questions about transition, call 1-877-7-NYSHIP and select the 2009MHSA option. When calling the toll free NYSHIPnumber, please listen carefully as optionswill change. You will be able to reachboth OptumHealth and ValueOptions fora period of time. Clinical Referral Lineservices will be provided by OptumHealthand continue to be available 24 hours aday/7 days a week.

Non-Network Inpatient Care, Partial Hospitalization, IntensiveOutpatient Program, Day Treatment, 23-hour Extended Bed and 72-HourCrisis Bed: 90% of Billed Charges (EMPIRE PLAN AT A GLANCE 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. Youpay the remaining 10 percent until you reach an inpatient coinsurance maximumof $1,500 for you, the enrollee, $1,500 for your enrolled spouse/domestic partnerand $1,500 for all enrolled dependent children combined. The Empire Plan thenpays 100 percent of billed charges for covered services. This benefit is not subjectto 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 of coinsurance,upon written request of the enrollee, then you pay the final $500 of coinsurance.This article also corrects the paragraph explaining Non-Network Coverage for Approved Facilities Under Mental Health Benefits on page 11 of yourEmpire Plan At A Glance.

70949_RET_EPR.qxp 3/27/09 5:33 PM Page 2

EPR-RETIREE-09-01 3

About Mental Health and Substance Abuse TransitionQuestions and Answers

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 youreceived network benefits between July 1, 2008 and December 31, 2008, you will automatically be given the transition of care benefit through March 31, 2009, for services received from the same provider, even if that provider is not in theOptumHealth network. Please note that thesebenefits apply to covered services received betweenJanuary 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 maycall if you have questions 24 hours a day, 7 days aweek. Call the NYSHIP toll-free number below, pressOption 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 2009MHSA option for OptumHealth. Provider networkinformation will 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.When the transition period ends on March 31, 2009,you must use an OptumHealth network provider toreceive the highest level of benefits. You may callOptumHealth at any time to access network benefits.If you continue treatment with your provider afterMarch 31, 2009 and your provider is not part of theOptumHealth network, your treatment will becovered under the non-network benefit, and you willhave 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 3 and selecting the 2009 MHSA option. Or, your provider may 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.

Q:A:

Q:A:

Q:A:

Q:

A:

Q:A:

Q:

A:

Q:

A:

The NYSHIP toll-free number is: 1-877-7-NYSHIP (1-877-769-7447).

70949_RET_EPR.qxp 3/25/09 4:19 PM Page 3

EPR-RETIREE-09-01 4

Flexible Formulary continued from page 1• Copayment levels for brand-name

drugs: 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 excluded fromcoverage under the 2009 Empire PlanFlexible 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 druglist once a year so in addition to theseexclusions, enrollees may notice otherbrand-name drugs that have a differentcopayment level as of January 1, 2009. If you have been taking one or more ofthese drugs, you should have already

received a letter informing you of thischange. You may want to discuss analternative medication with your doctorthat will result in your paying a lowercopayment. See your 2009 Empire PlanAt A Glance for a printed copy of theFlexible Formulary drug list or visit theDepartment of Civil Service web site atwww.cs.state.ny.us, select BenefitPrograms, then NYSHIP Online andchoose your group, if prompted.Alphabetic and therapeutic classversions of the 2009 Flexible Formularyare available under the Using YourBenefits button.

Instant Rebate for Omeprazole(generic Prilosec)For a limited time only, The Empire PlanPrescription Drug Program will offer aninstant rebate of your full copayment for omeprazole, the generic version ofPrilosec (the original “purple pill”). Thismedication is a proton pump inhibitorused in the treatment of peptic ulcers,gastroesophageal reflux disease (GERD)and other gastrointestinal symptoms.The instant rebate will apply to allomeprazole prescriptions filled atparticipating retail pharmacies or at amail service pharmacy between January 1and April 30, 2009. To receive your rebate(zero copayment), simply present yourprescription to your retail pharmacy orsend it to the mail service pharmacy. AfterApril 30, 2009, you will pay the applicablegeneric copayment ($5 or $10) forsubsequent refills. If you have questionsabout this rebate or your drug benefit, call The Empire Plan Prescription DrugProgram at 1-877-7-NYSHIP (1-877-769-7447) and choose option 4.

1 Excluded, except for treatment of growthfailure due to Prader-Willi syndrome orSmall for Gestational Age. Priorauthorization is required.

2 Excluded, except for treatment of growthfailure due to SHOX deficiency. Priorauthorization is required.

3 Excluded, except for treatment of shortstature associated with Noonan syndrome or small for Gestational age. Priorauthorization is required.

This voluntary program allows you toreduce the out-of-pocket cost of selectcovered prescription drugs you take ona regular basis by:• allowing your physician to write a

prescription for twice the dosage ofyour medication and half thenumber of tablets (see Example).

• having you split the pills in halfusing the free pill splitter that TheEmpire Plan will provide and

• instructing the participating retail pharmacy or the mail servicepharmacy to automatically reduce your copayment to half the normal charge:

ExampleOld Prescription: .............Lipitor 10 mgQuantity:.................................30 tabletsDosage: .....Take 1 tablet every morningCopayment .......................................$15

New Prescription:............Lipitor 20 mgQuantity:.................................15 tabletsDosage: ....Take ½ tablet every morningCopayment ....................................$7.50For a listing of drugs eligible for the Half Tablet Program, visit theDepartment of Civil Service web site at www.cs.state.ny.us. Select BenefitPrograms on the home page, thenNYSHIP Online and choose yourgroup, if prompted. Choose Using YourBenefits then Empire Plan Providers,Pharmacies and Services, scroll downto Medco and select Empire PlanPrescription Drug Half Tablet Program.

Splitting Tablets is EasyUsing a tablet splitter makes splittingyour medication easy. Never attempt to split tablets with anything other than a device designed specifically forthat purpose. Not all medications are

appropriate for tablet splitting. Consultyour doctor before splitting anyprescribed medication.

Order Free Tablet SplitterThe Empire Planwill offer a freetablet splitter toeach enrollee who is currentlyprescribed a drugthat is covered aspart of the Half Tablet Program. If youare on a medication eligible for thehalf-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 Costs

70949_RET_EPR.qxp 3/25/09 4:19 PM Page 4

Plan to attend a New York StateHealth Insurance Program (NYSHIP)retiree information meeting in yourarea this fall. These meetings are heldannually to help retirees, vestees anddependent survivors understand theirbenefits. A representative is on handto explain any benefit changes and toanswer your questions.Watch yourmailbox for a retireeinformationmeetingpostcard twoto three weeks before a meeting isscheduled in your area. You can alsofind the meeting schedule on theDepartment of Civil Service web siteat www.cs.state.ny.us. Click onRetirees, then Health Benefits to viewthe Calendar. Under Type of Event,scroll to Retiree Meeting.You don’t need a reservation to attend a NYSHIP retiree meeting, but seating is on a first-come, first-served basis. If you are unable to attend, you can send a family member, friend or other representative. The meetings are held at barrier-free sites. However, if you need a special accommodationsuch as a sign language interpreter,please call the Employee BenefitsDivision at 518-457-5754 (in theAlbany area) or 1-800-833-4344 fourto six weeks prior to the meeting date.

Albany • Monday, September 14Albany Marriott189 Wolf RoadAlbany, NY 12205

Binghamton • Friday, September 11Holiday Inn Arena2-8 Hawley StreetBinghamton, NY 13901

Brooklyn • Wednesday, November 18Brooklyn College Student CenterEast 27th Street and Campus RoadBrooklyn, NY 11210

Buffalo • Thursday, October 1Buffalo Niagara Marriott1340 Millersport HighwayAmherst, NY 14221

Latham • Wednesday, November 4Colonie Elks Lodge11 Elks LaneLatham, NY 12110

Manhattan • Thursday, November 19City University of New York Graduate Center365 5th Avenue (at 34th Street)New York, NY 10016

Plattsburgh • Thursday, September 24Holiday Inn Plattsburgh412 Route 3Plattsburgh, NY 12901

Poughkeepsie • Friday, September 25Poughkeepsie Grand Hotel40 Civic Center PlazaPoughkeepsie, NY 12601

Rochester • Friday, October 2Double Tree Hotel1111 Jefferson RoadRochester, NY 14623

Schenectady • Thursday, September 10Glen Sanders Mansion1 Glen AvenueScotia, NY 12302

Smithtown • Friday, October 16Sheraton Long Island110 Vanderbilt Motor ParkwaySmithtown, NY 11788

Syracuse • Monday, October 19Double Tree Hotel6301 State Route 298East Syracuse, NY 13057

Utica • Friday, September 18Radisson Hotel Utica Centre200 Genesee StreetUtica, NY 13502

Meetings 2009NYSHIP Health Benefits

You are invited to a meetingsponsored by the New York StateDepartment of Civil Service onyour New York State HealthInsurance Program (NYSHIP)retiree benefits. An agenda oftimely topics will be available onour web site (www.cs.state.ny.us).These meetings are held regularlyto help retirees, vestees and

dependent survivors understandtheir benefits. This meeting isoptional and not mandatory tocontinue benefits.You’ll also find the meetingschedule on the Department ofCivil Service web site. Click onRetirees, then Health Benefits toview the Calendar. Under Type ofEvent, scroll to Retiree Meeting.

AlbanySeptember 14, 20081:00 PM to 3:30 PM

Marriott Hotel189 Wolf RoadBallroom

Meeting Agenda

• NYSHIP General Information for Retirees• NYSHIP and Medicare• Medicare Advantage Plans• Empire Plan Benefit Changes for Retirees

No reservations are required. Seating is on a first-come, first-served basis and is notguaranteed. If you are unable to attend, you may send a representative. The meetingsite is handicapped accessible. Photo I.D. may be required.

You’re invited to a NYSHIP

retiree benefits meeting

September 14

70949_RET_Amends.qxp 3/25/09 4:23 PM Page 271

EPR-RETIREE-09-01 5

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 prescriptiondrug coverage to all enrollees under the Plan.Whenever a prescription drug is excluded, therapeuticbrand and/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 littleclinical difference in efficacy or adverse effects in theclass of prescription drugs that Nexium belongs to - proton pump inhibitors (PPIs). There is, however, a significant difference in the cost. The 2009 EmpirePlan Flexible Formulary continues to cover genericand other preferred brand-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 exclusionsis included 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 1-877-7NYSHIP (1-877-769-7447) and choosing Option 4. It is alsoavailable on the New York State Department of CivilService web site at www.cs.state.ny.us, and was mailed toall Empire Plan Participating Physicians and enrollees.

How will my local pharmacist know my drug isexcluded? Your local participating pharmacist will receive amessage when your claim is processed which willadvise that the drug is not covered under The EmpirePlan. If you choose to fill the prescription, you will beresponsible for paying the full cost of the drug; The

Empire Plan will not reimburse you for any portionof the cost.

What will happen if I send a new prescription orrequest a refill from Medco by Mail for an excludeddrug?If you call in a refill of an excluded drug through amail service pharmacy, the customer servicerepresentative or interactive voice response systemwill advise you that the drug is excluded, and yourorder will be cancelled. If you mail in a refill order,you will receive a letter indicating your drug is nolonger covered under the Plan. If you mail in a newprescription for an excluded drug, the mail servicepharmacy will return the prescription along with aletter advising that the drug is excluded from EmpirePlan coverage 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 E-Prescribing, a message willbe displayed indicating that the drug is not covered.

Where can I find lower cost alternatives to the drugI 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 talkwith your physician to identify which medication isappropriate to treat your condition.

How do I change to one of the preferredmedications on The Empire Plan FlexibleFormulary? Will I need a new 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 prescriptionof 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 chooseOption 4 for assistance.

Can I appeal a drug exclusion or tier placement?

No. Drug exclusions and level placements are acomponent of your Benefit Plan Design and cannotbe appealed.

Q:A:

Q:A:Q:A:

Q:A:

Q:A:

Q:A:

Q:

A:

Q:

A:

Q:A:

Q:A:

Q:A:

About The Empire Plan Flexible Formulary Questions and Answers

70949_RET_EPR.qxp 3/25/09 4:19 PM Page 5

EPR-RETIREE-09-01 6

RemindersThe Empire Plan At A Glance andCopayment CardsIn December 2008, the 2009 Empire PlanAt A Glance along with 2009 Empire PlanCopayment Cards and the 2009 FlexibleFormulary List were mailed to your home. All three are important pieces tounderstand your 2009 benefits; be sure to read them and keep them handy.

Participating Provider DirectoryThe most up-to-dateparticipatingprovider informationis available on theDepartment of CivilService web site atww.cs.state.ny.us.Click on BenefitPrograms and then onNYSHIP Online. Select your group, if prompted, and then click on Find AProvider. If you need a printed copy ofthe 2008 Empire Plan ParticipatingProvider Directory, call 1-877-7-NYSHIP(1-877-769-7447) toll free and chooseUnitedHealthcare. But remember thatthe MHSA listings are not correct (seepage 2).

2009 Annual Deductible andCoinsurance Maximum for BasicMedical and Non-Network MentalHealth Practitioner Services Annual Deductible: $363 Coinsurance Maximum: $1,000For calendar year 2009, The EmpirePlan annual deductible for servicesperformed and supplies prescribed by non-participating or non-networkproviders is $363 for you, $363 for your enrolled spouse/domestic partnerand $363 for all covered dependentchildren combined. You must meet the deductible beforebenefits are paid for your claims. The annual deductible for the BasicMedical Program and the non-networkportion of the Mental Health Programcannot be combined with each other or with the Managed Physical MedicineProgram annual deductible for non-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, domesticpartner and $1,000 for all covereddependent children combined in 2009.After each coinsurance maximum isreached, you will be reimbursed 100percent of the reasonable and customaryamount, or 100 percent of the billedamount, whichever is less, for coveredservices. You will still be responsible forany charges above the reasonable andcustomary amount and for any penaltiesunder the benefits managementprograms.

Annual Notice of Mastectomy andReconstructive Surgery BenefitsThe Empire Plan covers inpatient hospital care for lymph node dissection,lumpectomy and mastectomy fortreatment of breast cancer for as long asthe physician and patient determinehospitalization is medically necessary.The Plan covers all stages ofreconstructive breast surgery followingmastectomy, including surgery of theother breast to produce a symmetricalappearance. The Plan also coverstreatment for complications ofmastectomy, including lymphedema.

Prostheses and mastectomy bras are covered.Call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and select UnitedHealthcare if you have questions about your coverage forimplants, breast forms or other prosthesesrelated to breast cancer treatment.Empire Plan Benefits ManagementProgram requirements apply. See yourEmpire Plan Certificate and EmpirePlan Reports.

Reimbursement of the Medicare Part B Income-Related MonthlyAdjustment Amount (IRMAA) for Medicare-Primary EnrolleesMedicare law requires some people topay a higher premium for their MedicarePart B coverage based on their income.If you and/or any of your enrolleddependents are Medicare-primary andreceived a letter from the Social SecurityAdministration (SSA) requiring thepayment of an income-related monthlyadjustment amount (IRMAA) in additionto the standard 2008 Medicare Part Bpremium ($96.40) for 2008, you areeligible to be reimbursed for thisadditional premium by NYSHIP.Note: If your 2006 adjusted gross incomewas less than or equal to $82,000($164,000 if you filed taxes as marriedfiling jointly) you are NOT eligible forany additional reimbursement this year.To claim the additional IRMAAreimbursement, eligible enrollees arerequired to apply for and document theamount paid in excess of the standardpremium. For information on how toapply, a list of the documents requiredor questions on IRMAA, check theDepartment of Civil Service web site at www.cs.state.ny.us. Choose BenefitPrograms on the home page, thenNYSHIP Online and select your group, if prompted. The IRMAA letter, whichwas mailed to Medicare Part Breimbursement-eligible enrollees inOctober, is available under What’s Newon the NYSHIP Online home page. Orcall the Employee Benefits Division at518-457-5754 (if you are located in the518 area code) or 1-800-833-4344 betweenthe hours of 9:00 a.m. and 3:00 p.m.

70949_RET_EPR.qxp 3/25/09 4:19 PM Page 6

EPR-RETIREE-09-01 7

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 themessage. 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, Church Street Station, New York, NY 10008-1407. Web site: www.empireblue.com. Call for informationregarding hospital and related services.

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

Centers of Excellence for Transplants Program You must call Empire BlueCross BlueShield before ahospital admission for the following transplant surgeries: bone marrow, peripheral stem cell, cord bloodstem cell, heart, kidney, liver, lung and simultaneous 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 underParticipating Provider, Basic Medical Provider 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 findMPN network providers for chiropractic treatment and physical therapy. If you do not use MPN networkproviders, you will receive a significantly lower level of benefits.

Benefits Management Program for Prospective Procedure Review of MRI, MRA, CT, PET scans andNuclear Medicine tests You must call UnitedHealthcare before having an elective (scheduled) procedure ornuclear medicine test.

Home Care Advocacy Program (HCAP) You must call UnitedHealthcare to arrange for paid-in-full homecare services, enteral formulas, diabetic shoes and/or durable medical equipment/supplies. If you do notfollow HCAP requirements, you will receive a significantly lower level of benefits. You must also callUnitedHealthcare for HCAP approval of an external mastectomy prosthesis costing $1,000 or more.

Infertility Benefits You must call UnitedHealthcare for prior authorization for the following QualifiedProcedures, regardless of provider: Assisted Reproductive Technology (ART) procedures including in vitrofertilization and embryo placement, Gamete Intra-Fallopian Transfer (GIFT), Zygote Intra-Fallopian Transfer(ZIFT), Intracytoplasmic Sperm Injection (ICSI) for the treatment of male infertility, assisted hatching andmicrosurgical sperm aspiration and extraction procedures; sperm, egg and/or inseminated egg procurementand processing and banking of sperm and inseminated eggs. Call UnitedHealthcare for information aboutinfertility benefits and Centers of Excellence.

Centers of Excellence for Cancer Program You must call UnitedHealthcare to participate in The EmpirePlan Centers of Excellence for Cancer Program.

The Empire Plan Mental Health and Substance Abuse Program OptumHealth (administrator forUnitedHealthcare), Mailing Addresses: Claims/General Correspondence - OptumHealth Behavioral Solutions,

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 beginningany non-emergency treatment for mental health or substance abuse, including alcoholism. You will receive thehighest level of benefits by calling and following OptumHealth’s recommendations. In a life-threatening situation,go to the emergency room. Call within 48 hours or as soon as reasonably possible after inpatient admission.

The Empire Plan Prescription Drug Program UnitedHealthcare appeals, grievances, prior authorizationdocumentation, general correspondence: Empire Plan Prescription Drug Program, P.O. Box 5900, Kingston, NY 12402-5900.Claim forms from retail pharmacies: Empire Plan Prescription Drug Program, P.O. Box 14711, Lexington, KY 40512. MailService 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 Health Information Library, enter PIN number 335 and a four-digit topic code from The Empire PlanNurseLine 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

70949_RET_EPR.qxp 3/25/09 4:19 PM Page 7

EPR-RETIREE-09-01 8

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

EPR-RETIREE-09-01

CHANGE SERVICE REQUESTED

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

SAVE THIS DOCUMENT

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

Retiree Empire Plan Report – January 2009

This Report was printed using recycled paper and environmentally sensitive inks. AL0868

Please do not send mail orcorrespondence to the returnaddress. See page 2 foraddress information.!

NYSHIP Dependent Eligibility Verification ProjectIn 2009, the New York State Health Insurance Program (NYSHIP) will conductan audit of all dependents that have health care coverage through NYSHIP. Ifyou have family coverage you will receive a packet that will include a list of yourdependents who are currently enrolled for health care coverage, along with aneligibility worksheet and a list of required documents you must provide. Youmust supply the dependent documentation even if you have previously done so.Do not submit documents now – wait for the packet to be delivered. Go towww.cs.state.ny.us/nyshipeligibilityproject/index.cfm for information on theDependent Eligibility Verification Project. Bookmark the page and visit itperiodically for the most current information.You must provide the required documentation to ensure that your enrolleddependents continue to be covered under NYSHIP. Ineligible or unverifieddependents will be dropped from coverage. The Department of Civil Service is contracting with BUDCO, a dependentverification specialty company, to conduct the Dependent EligibilityVerification Project.

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

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. You should discuss this issue and yourpotential out-of-pocket liability with your non-participating provider beforeyou receive 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.

70949_RET_EPR.qxp 3/25/09 4:19 PM Page 8