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The Empire PlanBenefit Changes Effective January 1, 2005The Empire PlanHospital Benefits Program 50 Copayment for Emergency CareBeginning January 1, 2005, yourcopayment for emergency care in ahospital emergency room is 50.The 50 copayment covers use of thefacility for emergency care and servicesof the attending emergency roomphysician and providers who administeror interpret radiological exams,laboratory tests, electrocardiogramand pathology services.You will not have to pay the 50copayment if you are treated in theemergency room and then admittedat that time as an inpatient. 35 Copayment Per Outpatient VisitBeginning January 1, 2005, yourcopayment for outpatient servicesin a network hospital or hospitalextension clinic is 35 for each visitwhere you receive one or moreof the following services: surgery,diagnostic radiology, diagnosticlaboratory tests, administration ofDesferal for Cooley’s Anemia.You will not have to pay this 35facility copayment if you are treatedin the outpatient department of thehospital and then admitted at thattime as an inpatient.There continues to be no copaymentfor the following outpatient servicesin a network hospital: chemotherapy,radiation therapy, dialysis, pre-admissiontesting/pre-surgical testing beforeadmission as an inpatient. 15 Copayment for Physical TherapyBeginning January 1, 2005, yourcopayment is 15 for each visit to theoutpatient department of a networkhospital or hospital extension clinic forphysical therapy when covered underthe Hospital Benefits Program. Pleasesee your Empire Plan Certificate formore information.Hospital Extension ClinicsEffective January 1, 2005, The EmpirePlan covers charges, including facilitycharges, for hospital services coveredunder the Hospital Benefits Programand provided at network hospitalextension clinics. This coverage appliesto network hospital owned and operatedon-site facilities and facilities notphysically located in the hospitalbuilding, including ambulatory surgicalcenters. The hospital must bill for theservice as part of the hospital’s charges.Your copayment for emergency care ina hospital extension clinic is 50. Yourcopayment for outpatient services in anetwork hospital extension clinic is 35.You will not have to pay the emergencycare or outpatient services copayment ifyou are treated in the extension clinicand it becomes necessary for thehospital to admit you, at that time, asan inpatient. Please see this page andyour Empire Plan Certificate for detailsabout hospital coverage of emergencycare and outpatient services.With the exception of emergency care,non-network hospital benefits applyto services provided at extension clinicsin non-network hospitals. Page 2 of thisReport has more information aboutnetwork and non-network hospitals.The Empire PlanBenefits Management ProgramHospital CoverageEffective January 1, 2005, you willbe responsible for the full cost of anyinpatient hospital day determined tobe not medically necessary. YourEmpire Plan Certificate has informationabout your right to appeal if you arecharged for inpatient days that can bedocumented as medically necessary.The Empire PlanMedical/Surgical Benefits Program 15 CopaymentBeginning January 1, 2005, you pay a 15copayment for services by Empire Planparticipating providers that are subject tocopayments. Such services include officevisits, office surgery, radiology services,diagnostic laboratory services, cardiacrehabilitation center visits, urgent carecenter visits and contraceptive drugs anddevices dispensed in a doctor’s office.Your copayment for services by ManagedPhysical Network (MPN) providers is also 15 as of January 1, 2005.Radiology, Anesthesiology, PathologyBeginning January 1, 2005, if you receiveradiology, anesthesia or pathologyservices in connection with inpatient oroutpatient hospital services at an EmpirePlan network hospital, covered chargesbilled separately by the radiologist,anesthesiologist or pathologist will bepaid in full by United HealthCare.Services provided by other specialtyphysicians in an Empire Plan networkhospital continue to be consideredunder the Participating ProviderProgram or the Basic Medical Program.Basic Medical Annual Deductible: 309For calendar year 2005, The Empire PlanBasic Medical Program annual deductiblefor medical services performed andsupplies provided by non-participatingproviders is 309 for you, 309 for yourenrolled spouse/domestic partner and 309 for all covered dependent childrencombined. This change is due to anincrease in the Consumer Price Index.Basic Medical ProgramCoinsurance Maximum: 1,486The annual coinsurance maximum(out-of-pocket costs) under the BasicMedical Program is 1,486 in 2005.The annual coinsurance maximumwill increase on January 1 of each yearbased on the percentage increase inthe Consumer Price Index.Benefit Changes continued on page 4EPR-PEF-04-23

Benefit Changes continued from page 3Prostheses and Orthotic DevicesEffective January 1, 2005, The EmpirePlan includes a nationwide network ofcertified suppliers of prostheses andorthotic devices under the ParticipatingProvider Program. When you use anEmpire Plan participating provider, youhave a paid-in-full benefit, with nocopayment, for prostheses and orthoticdevices. The Empire Plan benefitprovides for a prosthesis or an orthoticdevice meeting the individual’sfunctional needs. Replacements, whenfunctionally necessary, are also covered.Participating providers will offeradjustments to custom-fitted devicesand appropriate follow-up care.If your need is urgent, and/or youare unable to travel to the provider’soffice, some participating providerswill guarantee an appointment withinthree days and will travel up to onehour to your home. Ask the providerdirectly or call United HealthCare at1-877-7-NYSHIP (1-877-769-7447)toll free.A list of Empire Plan providers ofprostheses and orthotic devices willbe available on the New York StateDepartment of Civil Service web siteat www.cs.state.ny.us before the end ofthe year. Click on Employee Benefitsand choose Empire Plan Providers andPharmacies. Or, call United HealthCareat 1-877-7-NYSHIP (1-877-769-7447)toll free.Prostheses and orthotic devices fromnon-network providers are coveredunder the Basic Medical Program.External Mastectomy ProsthesesEffective January 1, 2005, one singleor double external mastectomyprosthesis per calendar year iscovered in full under the BasicMedical Program. This benefit has nodeductible, coinsurance or copayment.Any single external mastectomyprosthesis costing 1,000 or morerequires approval through the HomeCare Advocacy Program (HCAP). CallHCAP toll free at 1-877-7-NYSHIP(1-877-769-7447) and choose United4EPR-PEF-04-2HealthCare before you purchase theprosthesis. For a prosthesis requiringapproval, if a less expensive prosthesiscan meet an individual’s functionalneeds, benefits will be available for themost cost-effective choice.After purchasing a mastectomyprosthesis, submit a completed claimform to United HealthCare with theoriginal itemized receipt. (See addresson page 11 of this Report.) UnitedHealthCare will send reimbursementfor the prosthesis directly to you.The Empire Plan continues to covermastectomy bras under the BasicMedical Program. Please see yourEmpire Plan Certificate for information.Hearing AidsBeginning January 1, 2005, under theBasic Medical Program, coverage forhearing aids, including evaluation,fitting and purchase, increases up toa total maximum reimbursement of 1,200 per hearing aid, per ear. Theincreased benefit is available once inany four-year period for each ear. Forchildren age 12 years and under, theincreased benefit is available once inany two-year period for each earwhen the child’s hearing has changedand the existing hearing aid(s) nolonger fills the need.These benefits are not subject todeductible or coinsurance.The Empire PlanHospital Benefits Program andMedical/Surgical Benefits ProgramInfertility Benefits MaximumBeginning January 1, 2005, the lifetimemaximum for certain infertility benefits,called Qualified Procedures, increasesto 50,000 per individual. This is anincrease from the 25,000 lifetimemaximum. Please see your EmpirePlan Certificate and Empire PlanReports for information about EmpirePlan infertility benefits and QualifiedProcedures.The Empire PlanMental Health andSubstance Abuse Program 15 Copayment for OutpatientSubstance Abuse TreatmentBeginning January 1, 2005, you paya 15 copayment for each visit toan approved Structured OutpatientRehabilitation Program for substanceabuse. The copayment for an outpatientmental health visit remains 15. Toqualify for benefits, all covered servicesmust be certified as medically necessaryby ValueOptions. 50 Copayment for Emergency Carefor Mental Health/SubstanceAbuse TreatmentEffective January 1, 2005, yourcopayment for emergency care in ahospital emergency room is 50.You will not have to pay this 50copayment if you are treated in theemergency room and then admittedat that time as an inpatient. When youreceive medically necessary coveredservices from a non-network providerin a certified emergency, the Programwill provide network coverage until youcan be transferred to a network facility.

Basic Medical ProviderDiscount Program Available October 1, 2004The following applies to enrollees whohave primary coverage through TheEmpire Plan.Beginning October 1, 2004, The EmpirePlan includes a new program to reduceyour out-of-pocket costs when you use anon-participating provider. This newprogram, The Empire Plan BasicMedical Provider Discount Program,offers discounts from certain physiciansand other providers who are not partof The Empire Plan participatingprovider network. These providers arepart of the MultiPlan group, anationwide provider organizationcontracted with United HealthCare.Providers in the Basic Medical ProviderDiscount Program accept a discountedfee for covered services. You will not bebilled for charges over the discountedfee. Empire Plan Basic Medical Programprovisions apply. You must meet theannual deductible. However, your 20percent coinsurance is based on thediscounted fee, not the reasonable andcustomary charges as under the BasicMedical Program. So, you again saveon costs. Plus, you have no claims tofile. The provider will submit claimsfor you and United HealthCare will paythe provider directly. Your Explanationof Benefits, which details claimspayments, will show the discountapplied to billed charges.To find a provider in The Empire PlanBasic Medical Provider DiscountProgram, ask if the provider is anEmpire Plan MultiPlan provider or call1-877-7-NYSHIP (1-877-769-7447) tollfree, choose United HealthCare and ask arepresentative for help. You can also visitthe New York State Department of CivilService web site at www.cs.state.ny.us.Click on Employee Benefits, then onEmpire Plan Providers and Pharmacies.United HealthCare hasmailed you a postcard witha MultiPlan sticker. Pleaseplace the sticker on yourNew York Government Employee BenefitCard. If you have not received thepostcard, you may call United HealthCareat 1-877-7-NYSHIP (1-877-769-7447)toll free and ask for one.The Basic Medical Provider DiscountProgram will be especially helpful toyou when you or your dependents aretraveling or away at school in an areawhere participating providers are noteasily available. With the addition ofthis Program, you have another way tomanage your health care costs.Centers of Excellencefor Cancer Program Available October 1, 2004If you or a covered dependent isdiagnosed with cancer, think aboutusing The Empire Plan Centers ofExcellence for Cancer Program. TheProgram provides paid-in-full coveragefor cancer-related expenses receivedthrough a nationwide network knownas Cancer Resource Services (CRS).To participate in this voluntaryprogram, you must call The EmpirePlan toll free at 1-877-7-NYSHIP(1-877-769-7447). Press or say 1 forUnited HealthCare and then press orsay 5 to connect to a Cancer ResourceServices nurse consultant. Or, call theCRS toll-free number, 1-866-936-6002.Nurses are available from 8 a.m. to8 p.m. Eastern time, Monday throughFriday except holidays.CRS nurse consultants are experiencedcancer nurses. They can answer yourquestions, help you understand a cancerdiagnosis and cancer treatment optionsand provide support if you or a familymember is diagnosed with cancer. CRSnurses can also help you choose the bestphysician and cancer center fortreatment of the specific kind of cancer.When you use a Center of Excellence forCancer, you receive paid-in-full benefitswith no copayment. The CRS networkincludes many of the nation’s leadingcancer centers. Among them areMemorial Sloan-Kettering CancerCenter in New York City, Roswell ParkCancer Institute in Buffalo, and, inBoston, Dana-Farber Cancer Institute,Brigham & Women’s Hospital andMassachusetts General Hospital.If you choose to go to a Cancer Centerof Excellence located more than 100miles from your home, the Plan willassist you and one travel companionwith expenses for travel, lodging andmeals. You can find more informationabout Cancer Resource Services onlineat www.urncrs.com, the CRS web site.Since the Centers of Excellence forCancer Program is voluntary, you arestill eligible for Empire Plan benefitsfor your medically necessary cancertreatment if you do not use theProgram. However, you must followthe requirements of the BenefitsManagement Program and pay anyapplicable deductible, coinsuranceand copayments.EPR-PEF-04-25

NYSHIPThe Empire PlanChangesPrescription Drug ProgramCopayment Changes Effective January 1, 2005Beginning January 1, 2005, The Empire Plan Prescription Drug Programincludes generic, preferred brand-name and non-preferred brand-name drugs.Your copayment amount depends on the drug and quantity prescribed and whereyou fill your prescription.Prescription Drug Copayment ChartSupply DispensedUp to a 30-day supplyfrom a participating retailpharmacy or throughthe Express ScriptsMail Service Pharmacy31- to 90-day supplythrough the ExpressScripts Mail ServicePharmacy31- to 90-day supplyfrom a participatingretail nd-name 5copayment 15copayment 30copayment 5copayment 20copayment 55copayment 10copayment 30copayment 60copaymentA list of the most commonly prescribed generic and preferred brand-namedrugs is on the New York State Department of Civil Service web site atwww.cs.state.ny.us. Click on Employee Benefits and choose your group-specificbenefits. Or, call The Empire Plan Prescription Drug Program toll free at1-877-7-NYSHIP (1-877-769-7447). Choose Express Scripts.Generic SubstitutionIf your prescription is written for a brand-name drug that has a generic equivalent,The Empire Plan continues to cover only the cost of the drug’s generic equivalent.If your prescription is written for a brand-name drug with a generic equivalent,you pay the non-preferred brand-name copayment plus the difference in costbetween the brand-name and generic drug, not to exceed the full cost of the drug.Certain drugs are excluded from this requirement. You will be responsible for theapplicable preferred brand-name or non-preferred brand-name copayment.Your Empire Plan Certificate has information about appealing the genericsubstitution requirement.6Domestic Partner EligibilityEffective January 1, 2005, to enrolla domestic partner, you must be ableto provide proof that you have livedtogether and been financiallyinterdependent for at least six months.Also effective January 1, 2005, thereis a one-year waiting period from thetermination date of previous partnercoverage before you may again enrolla domestic partner. Other eligibilityrequirements apply. Please see yourNYSHIP General Information Bookand Empire Plan Reports for details.Disability RetirementIf you receive a retroactive disabilityretirement and have not continuedyour coverage, call the EmployeeBenefits Division at 518-457-5754(Albany area) or 1-800-833-4344 toask about reinstating coverage. Callas soon as you have the decision onyour disability retirement. You mustapply in writing for reinstatement ofyour NYSHIP coverage.Please see your NYSHIP GeneralInformation Book and Empire PlanReports for more information aboutdisability retirement.Medicare and COBRA CoverageIf you become eligible for Medicareafter enrolling in COBRA, yourCOBRA coverage ends when youbecome entitled to receive Medicarebenefits. Your covered dependentsmay continue COBRA coverage forthe balance of 18 months from theiroriginal COBRA-qualifying event.Report continued on page 7EPR-PEF-04-2

Report continued from page 6Questions and AnswersAbout New BenefitsQ:A:Q:A:Q:A:Q:A:How will I know if my hospital is inThe Empire Plan network?A directory of Empire Plan network hospitals isavailable on the New York State Department of CivilService web site at www.cs.state.ny.us. ChooseEmployee Benefits and then click on Empire PlanProviders and Pharmacies. Or, you can callThe Empire Plan toll free at 1-877-7-NYSHIP(1-877-769-7447) and choose Empire Blue CrossBlue Shield to ask a representative.Is the hospital network access standard of within30 miles of residence always based on mypermanent address?Not necessarily. For example, if you are temporarilyliving in another location or have a dependent, such as acollege student, who is residing at another location, thePlan will approve network coverage at a non-networkhospital if no network facility meets the access standardbased on the place of residence at that time.If my Empire Plan medical provider has privilegesonly at a non-network hospital and that is the hospitalI use, will I receive network or non-network hospitalbenefits? What if my Empire Plan provider sends meto a non-network hospital for lab work?If you receive services at a non-network hospitaland a network hospital is within 30 miles of yourresidence, you will receive non-network benefits andhave out-of-pocket expenses. You will also receivenon-network benefits if your provider sends you to anon-network hospital for lab work when a networkhospital is within 30 miles of your residence.Will I get reimbursed for non-network hospitalcoinsurance amounts?Yes. When your combined coinsurance payments forservices at a non-network facility are more than 500for you, more than 500 for your spouse/domesticpartner or more than 500 for all enrolled dependentchildren, you may send a completed claim form toUnited HealthCare for reimbursement. You will bereimbursed for the amount over 500, up to the nonnetwork hospital coinsurance maximum of 1,500. Anynetwork level copayments paid at non-network hospitals(emergency care copayment) do not count toward thecoinsurance maximum.For example, you receive services at a non-networkhospital and have an out-of-pocket expense of 400 incoinsurance. You again go to a non-network hospitalin the same calendar year and pay another 400coinsurance. You have a combined out-of-pocketexpense of 800. You can now submit a claim to UnitedHealthCare for reimbursement of 300.Q:A:How will I know if my prescription is fora generic or a preferred brand-name drug?Q:A:Will my doctor know The Empire Plangeneric and preferred brand-name drugs?Q:A:Does the Basic Medical Provider DiscountProgram replace the Basic Medical Program?Q:A:Why would I use the Basic Medical ProviderDiscount Program?You’ll find a list of the most commonly prescribedgeneric and preferred brand-name drugs on theDepartment of Civil Service web site atwww.cs.state.ny.us. Choose Employee Benefitsand then your group-specific benefits. Or, you maycall The Empire Plan toll free at 1-877-7-NYSHIP(1-877-769-7447). Choose Express Scripts.The Empire Plan will provide doctors with the list ofmost commonly prescribed generic and preferredbrand-name drugs. But, it is your responsibility toknow in which category your drug is listed. Get thelist from the web site or the Plan (see above) beforeyour doctor’s appointment.No. The Basic Medical Provider Discount Program ispart of the Basic Medical Program. You may still chooseto receive care under the Participating ProviderProgram. Or, you may choose non-participatingproviders under the Basic Medical Program.When a participating provider is not available, or youchoose to go to a non-participating provider, the BasicMedical Provider Discount Program (MultiPlan) cansave you money. After you meet your deductible, youare responsible for 20 percent of the discounted fee.The MultiPlan provider cannot balance bill you foramounts exceeding the discounted fee.For example, you have met your deductible for theyear and receive services costing 200. The MultiPlandiscounted fee is 140. Your cost is 28 (20 percent ofthe discounted fee). Plus, the provider submits theclaim for you and United HealthCare pays the provider.In contrast, for the same 200 cost of services under theBasic Medical Program for non-participating providers,The Empire Plan pays 128 (80 percent of the reasonableand customary charge of 160). Your cost is 72 (thedifference between 200 and 128). And, you must filethe claim for reimbursement yourself.EPR-PEF-04-27

Empire Plan RemindersThe Empire Plan NurseLine SMYour Plan is The Empire PlanClaims DeadlinesYou can call The Empire PlanNurseLine 24 hours a day, seven daysa week for health informationand support. Call 1-877-7-NYSHIP(1-877-769-7447) toll free and press orsay 5 to talk with a registered nurse orto reach The Empire Plan NurseLine’sHealth Information Library.For recorded messages on more than1,000 topics, enter PIN number 335and a four-digit topic code from TheEmpire Plan NurseLine brochure. Ifyou do not have your brochure, askthe NurseLine nurse to send you one.The New York State HealthInsurance Program(NYSHIP) providesyour healthinsurancebenefitsthrough The Empire Plan.The Empire Plan is designedespecially for New York’s publicemployees and their families by theState and employee unions.In New York State, the Empire State,you’ll hear the word “Empire” againand again, even linked to other healthplans. The correct name of your healthinsurance plan is The Empire Plan.The correc

Benefits, then on Empire Plan Providers and Pharmacies. You can also call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose Empire Blue Cross Blue Shield. Non-network Benefits If you, your enrolled spouse/domestic partner or your dependent child chooses to use a non-network hospital, hospice or