January 1, 2007

REVISED

This guide briefly describes the principal NYSHIP SEHP benefits. It is not a complete description and is subject to change.

If you have questions about eligibility, enrollment procedures or the cost of health insurance, contact the agency Health Benefits Administrator on your campus.

For more detailed benefit information call the insurance carriers below.

Contents

Eligibility, Enrollment, and Cost
SEHP Health Insurance Benefit Summary
Benefits Management Program
Inpatient and Outpatient Hospital Coverage
Medical/Surgical Coverage
Managed Physical Medicine Program (MPN)
Home Care Advocacy Program (HCAP)
Mental Health and Substance Abuse Program
Prescription Drug Program
Exclusions
SEHP Dental Care Benefit Summary
SEHP Vision Care Benefit Summary

Benefit Summary

The NYSHIP Student Employee Health Plan (SEHP) is a health insurance program for SUNY graduate and teaching assistant employees and their families. The plan provides medical, dental and vision care benefits.

Call Toll Free 1-877-7-NYSHIP (1-877-769-7447)

For pre-authorization of services or if you have a question about providers or claims, please call toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the carrier you need. United HealthCare and Empire BlueCross BlueShield representatives are available Monday through Friday, 8 a.m. to 5 p.m. Eastern time. ValueOptions and Prescription Drug Program representatives are available 24 hours a day, seven days a week. This number is for both The Empire Plan (another NYSHIP plan) and NYSHIP SEHP (except for the NurseLine option, which is for The Empire Plan only). SEHP dental and vision care plans have separate toll-free numbers.

Hospital Benefits Program insured and administered by Empire BlueCross BlueShield*

Provides coverage for inpatient and outpatient services provided by a hospital or B irthing center and for hospice care. Also provides inpatient Benefits Management Program services for pre-admission certification of scheduled hospital admissions or within 48 hours after an emergency or urgent admission.
* Services provided by Empire Healthchoice Assurance, Inc., an independent licensee of the BlueCross BlueShield Association.

Medical/Surgical Benefits Program insured and administered by UnitedHealthcare

Provides coverage for medical services, such as office visits, surgery and diagnostic testing under the network and non-network programs. Coverage for chiropractic care and physical therapy is provided through the Managed Physical Medicine Program. Home care services provided in lieu of hospitalization and diabetic supplies provided by the Home Care Advocacy Program. Benefits Management Program services for Prospective Procedure Review of Magnetic Resonance Imaging (MRI).

Managed Mental Health and Substance Abuse Program insured by GHI and administered by ValueOptions

Provides coverage for inpatient and outpatient mental health and outpatient substance abuse services..

Prescription Drug Program insured by Empire BlueCross BlueShield and jointly administered by Empire BlueCross BlueShield and Caremark

Provides coverage for prescription drugs, oral contraceptives and diaphragms through network pharmacies, the Caremark Mail Service pharmacy and non-network pharmacies.

Dental Care Plan administered by GHI 1-800-947-0101

Provides coverage for dental examinations, cleaning and bitewing X-rays. Also provides discounts on other services.

Vision Care Plan administered by EyeMed 1-877-226-1412

Provides coverage for routine eye examinations, eyeglasses or contact lenses.

Eligibility, Enrollment, and Cost

Who is Eligible?

This section explains eligibility requirements for the NYSHIP SEHP coverage for you (the enrollee) and your dependents. You must be represented by the GSEU and enrolled for NYSHIP SEHP coverage to be eligible for benefits.

You, the enrollee

1. Graduate student employees eligible for an employer contribution under the NYSHIP SEHP are those who work at least one-half an assistantship and are employed at a stipend that would yield a total compensation of $4,002 or more for the contract year July 1, 2006 through June 30, 2007.
2. Employees who work at least one-half an assistantship but are hired mid-year will be eligible if they earn a stipend that would yield a total compensation equal to $4,002 or more when annualized from the July 1, 2006 through June 30, 2007 contract year.
3. A graduate student employee (and his/her dependents) currently enrolled in NYSHIP's Empire Plan or a NYSHIP HMO as an employee of New York State, a Participating Employer or a Participating Agency is also eligible for coverage under the NYSHIP SEHP.

SUNY graduate student employee Visa holders

SUNY J1 Visa holders are not eligible to enroll in SEHP. They must enroll for coverage under the State University of New York Medical Insurance Program for International Students and Scholars subject to the coverage requirements of federal regulations.

SUNY F1 Visa holders who meet the eligibility requirement for an employer contribution must enroll in the NYSHIP SEHP. The State University may waive this requirement to enroll if the F1 Visa holder can show proof of other coverage that, in the State University's judgment, meets or exceeds the coverage provided by the NYSHIP SEHP.

Your dependents

The following dependents are eligible for coverage:

• Your spouse
  Your spouse, including a legally separated spouse, is eligible. If you are divorced or your marriage has been annulled, your former spouse is not eligible, even if a court orders you to maintain coverage. However, an ex-spouse may be eligible to purchase a contract under COBRA if a timely application is made (see below). You may also cover your same sex spouse, if the marriage is legal in the jurisdiction where it was performed.
  Or your domestic partner
  You may cover your same or opposite sex domestic partner as your dependent. A domestic partnership, for eligibility under the Plan, is one in which you and your partner are 18 years of age or older, unmarried and not related in a way that would bar marriage. You must be living together, involved in a lifetime relationship and financially interdependent. At the time of application, you must have been in the partnership for six months. Agency Health Benefits Administrators have complete information on eligibility, enrollment procedures and coverage dates.
• Your child under age 19
  Your unmarried dependent children are eligible until they reach age 19. This includes your natural children, legally adopted children including children in a waiting period prior to finalization of adoption, and your dependent stepchildren. Other children who reside permanently with you in your household, who are chiefly dependent on you for support (50 percent or more) and for whom you have assumed legal responsibility in place of the parent are also eligible.
• Disabled child age 19 or over
  Your unmarried dependent children age 19 or over who are incapable of supporting themselves because of a mental or physical disability are eligible if the disability began before age 19. You must apply no more than 60 days after the child's 19th birthday. You must provide medical documentation.

Questions?

If you have any questions concerning eligibility, please contact the agency Health Benefits Administrator on your campus, usually in the Human Resources (Personnel) office.

Enrollment and Effective Dates of Coverage

How to enroll

Eligible student employees may enroll as follows:

1. Within 45 days of first becoming eligible for coverage
2. During an annual open enrollment period, which is set by SUNY each year, usually from mid-August through late September
3. Upon involuntary loss of other coverage
4. At any time, with a 30-day waiting period before coverage begins

For domestic students (U.S. citizens and permanent residents), enrollment is optional except at campuses where health insurance coverage is mandated by the campus (e.g. University at Buffalo). See below for further information on mandatory enrollment.

Your agency Health Benefits Administrator will give you benefit plan information. Your identification card(s) will be mailed to you after you have enrolled.

A student employee who does not enroll his/her dependents at the time of initial enrollment may do so within 30 days of one of the following "Qualifying Events":

• Marriage
• Birth of a baby
• Employee becoming a child's legal guardian, step-parent, or adoptive parent
• Arrival of an eligible dependent in the United States
• Completion of the six-month waiting period for attainment of domestic partnership status
• Involuntary loss of other coverage

You are responsible for notifying your agency Health Benefits Administrator when you or your dependents are no longer eligible for coverage.

Mandatory enrollment of U.S. citizens and permanent residents at certain campuses

Domestic students at campuses where enrollment for health insurance coverage is mandated by the campus must enroll in the SEHP during the open enrollment or within 45 days of first becoming eligible, if they meet the eligibility requirements for an employer contribution and are not otherwise eligible to have the coverage requirement waived. Failure either to obtain a health insurance waiver or to enroll in the SEHP in a timely manner may result in the employee's being automatically enrolled in the mandatory student health insurance program provided by the campus. The cost of the coverage provided by the campus would be paid entirely by the student.

No coverage during waiting period

Expenses incurred or services rendered during a waiting period will not be covered. Be sure to keep any other insurance you may have in effect, if possible, to cover expenses until your NYSHIP SEHP coverage becomes effective.

EFFECTIVE DATES FOR NEW ENROLLMENTS

Event	Effective Date
Newbenefits-eligible appointment� application received within 45 days of appointment	Date the enrollment form is received in the SUNY Human Resources office, or the effective date of the appointment, whichever is later. Exceptions: Employees on F1 Visas must have coverage as of their date of appointment. Domestic students at campuses where health insurance enrollment is mandated by the campus must have coverage as of their date of appointment.
Annual Open Enrollment Period (45-day period determined by SUNY)	Date the enrollment form is received in the SUNY Human Resources office, if received within the 45-day period
Within 30 days of involuntary loss of other coverage	Date the enrollment form is received in the SUNY Human Resources office
All Others	30 days after the enrollment form is received in the SUNY Human Resources office

EFFECTIVE DATES FOR ADDITION OF DEPENDENTS

Event	Effective Date
Within 30 days of Qualifying Event	Date of the event
Within 30 days of involuntary loss of other coverage	Date the enrollment form is received in the SUNY Human Resources office
All Others	30 days after the enrollment form is received in the SUNY Human Resources office

Summer enrollment

Eligible student employees who are employed and enrolled in the spring semester and are expected to return in the subsequent fall semester will be eligible for an employer contribution during the intervening summer. The employee's department must verify that the employee is expected to return. Arrangements will be made to collect the employee portion of the NYSHIP SEHP contribution for the summer from the eligible employee prior to the end of the spring semester. Employees not enrolled during the spring semester may not enroll during the summer semester.

ID Cards; Provider Directory

New enrollees/dependents receive three identification cards: one for hospital, medical, surgical, mental health/substance abuse and prescription drug benefits; one for dental benefits; and one for vision benefits.

Your agency Health Benefits Administrator will give you a Participating Provider Directory listing medical/surgical providers, hospitals and mental health/substance abuse providers for NYSHIP's Empire Plan enrollees. This directory also applies to NYSHIP SEHP enrollees except for references to the ID card and listings of cardiac rehabilitation centers. Network benefits for the NYSHIP SEHP are available to you when you receive medically necessary care from any provider who is under contract to United HealthCare or ValueOptions to provide services to Empire Plan enrollees. For the most current provider listing, you may search the Participating Provider Directory.

Cost

The State will contribute 90 percent of the cost of individual coverage and 75 percent of the additional cost for dependent coverage. You pay your share of the premium through biweekly paycheck deductions. Refer to "Your Cost" for the employee share of the premium for 2007.

Benefits after termination of coverage

If you are totally disabled (because of sickness or injury you cannot do your job or your dependent cannot do his or her usual duties) on the date coverage ends on your account, your health insurance plan will pay benefits for covered medical expenses for that total disability, on the same basis as if coverage had continued without change, until the day you are no longer totally disabled or 90 days after the day your coverage ended, whichever is earlier.

Appeals

If a claim for benefits payment or a request for precertification is denied in whole or in part, you have the right to begin an appeal process with the carrier. You must write to the carrier within 60 days after the claim payment date or the date of the notification of denial of benefits. After you have followed the carrier's internal appeals process, under certain circumstances, you have the right to an External Appeal of a denial of coverage made on the basis that the service is not medically necessary or is an experimental or investigational treatment. You or your representative may appeal for review of that decision by an External Appeal Agent, an independent entity certified by the New York State Department of Insurance to conduct such appeals. You must file your request with the Insurance Department (1-800-400-8882) within 45 days of either the date upon which you receive written notification from a carrier that it has upheld a denial of coverage or the date upon which you receive a written waiver of an internal appeal.

When coverage ends

Your coverage in NYSHIP SEHP will end 28 days after the last day of the last payroll period worked, even if your identification card has a different termination date. Do not use your card after coverage ends. It is insurance fraud for an enrollee or dependent to use the card to obtain services after eligibility for coverage ends.

COBRA: Continuation of Coverage

If you wish to continue NYSHIP SEHP benefits after your employment-based eligibility ends, you and your covered dependents have the right to elect COBRA within 60 days of your last day of coverage. Employees receive a COBRA application automatically when employment ends. Dependents may enroll in COBRA by writing to the Employee Benefits Division.

Conversion Contracts

If your employment with SUNY in a benefits-eligible position ends, or your dependent loses eligibility, you/your dependent will be entitled to direct-pay conversion contracts after NYSHIP coverage ends or after COBRA coverage in NYSHIP is exhausted. You do not need to provide evidence of insurability. The benefit package and premium costs for direct-pay conversion contracts will differ from what you have had under NYSHIP. Contact Empire BlueCross BlueShield and United HealthCare for information. You will have 90 days from the date NYSHIP coverage ends to apply for conversion coverage.

SEHP Health Insurance Benefit Summary

Annual Benefit Maximums

Annual maximum for prescription drugs, network and non-network combined: $2,500. The Annual Benefit Maximums for all other NYSHIP SEHP coverage, except prescription drugs:

Non-network benefits: $100,000

All benefits (network and non-network combined): $350,000

All services must be medically necessary. "Allowable expenses" or "allowable amount" means the amount you actually paid for medically necessary services covered under SEHP, or the network allowance as determined by the carriers, whichever is lower.

Benefits Management Program

for pre-admission certification

If NYSHIP SEHP coverage is primary for you or your covered dependents:

You must call the Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and choose Empire BlueCross BlueShield:

• Before a scheduled (non-emergency) hospital admission
• Before a maternity hospital admission
• Within 48 hours after an emergency or urgent hospital admission

If you do not call, or if Empire BlueCross BlueShield does not certify the hospitalization, the Plan pays up to 50 percent of allowable expenses after your $200 copayment.

Prior Authorization of Magnetic Resonance Imaging (MRI)

If NYSHIP SEHP coverage is primary for you or your covered dependents:

You must call the Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose United HealthCare for prior authorization before having a scheduled (non-emergency)Magnetic Resonance Imaging (MRI), unless you are having the test as an inpatient in a hospital. If you do not call, you will pay a large part of the costs. If the MRI is determined to be not medically necessary, you will be responsible for the entire cost.

Inpatient and Outpatient Hospital Coverage

Empire BlueCross BlueShield New York State Service Center, P.O. Box 1407, Church Street Station, New York, NY 10008-1407

Empire BlueCross BlueShield pays for covered services provided in an inpatient or outpatient hospital setting. United HealthCare provides benefits for certain medical and surgical care provided in a hospital setting when it is not covered by Empire BlueCross BlueShield. Call the Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and choose Empire BlueCross BlueShield if you have questions about your hospital benefits, coverage or an Explanation of Benefits statement.

Hospital Inpatient • Semi-Private Room or Birthing Center

Network Coverage	(or) Non-Network Coverage
for pre-admission certification
Copayment: $200 per person per admission; new copayment required if hospitalization occurs more than 90 days after previous discharge.	Copayment: $200 per person per admission; new copayment required if hospitalization occurs more than 90 days after previous discharge.
Coverage level: The Plan pays 100 percent of allowable amount after you pay the copayment.	Coverage level: The Plan pays 80 percent of allowable amount after you pay the copayment. You are responsible for the balance.
Unlimited days for covered medical or surgical care in a hospital, except inpatient detoxification which is limited to 7 days per person per year.	Unlimited days for covered medical or surgical care in a hospital, except inpatient detoxification, which is limited to 7 days per person per year.
Maternity Care: First 48 hours of hospitalization for mother and newborn after any delivery other than a cesarean section or first 96 hours following a cesarean section are presumed medically necessary and covered at the same copayment and coverage level as other inpatient admissions. If you choose early discharge following delivery, you may request one paid-in-full home care visit.	Same as network coverage.

Hospital Outpatient

Network Coverage	(or) Non-Network Coverage
Surgery, diagnostic radiology, diagnostic laboratory tests, bone mineral density screening and administration of Desferal for Cooley's Anemia in the hospital outpatient department of a network hospital (or an extension clinic, including ambulatory surgical centers) are subject to one copayment of $15 per visit. The copayment is waived if you are admitted as an inpatient directly from the outpatient department. For Magnetic Resonance Imaging (MRI), you must have prior authorization.	Outpatient Care: Same as network coverage, except subject to an annual deductible of $100 per covered individual. (Not combined with physical therapy deductible.) Coinsurance: The plan pays 80 percent of allowable expenses after you meet the $100 deductible.
$10 copayment per visit for up to 60 visits for medically necessary physical therapy following a related hospitalization or related inpatient or outpatient surgery.	Non-network coverage subject to a separate $100 deductible for all physical therapy. (Not combined with hospital outpatient deductible.)
Emergency Room services, including use of the facility for emergency care and services of the attending emergency room physician and providers who administer or interpret radiological exams, laboratory tests, electrocardiogram and pathology services are subject to one copayment of $25 per visit. The copayment is waived if you are admitted as an inpatient directly from the emergency room. Emergency is defined as the sudden onset of symptoms of sufficient severity, including severe pain, that a prudent layperson could reasonably expect the absence of immediate care to put the person's life in jeopardy or cause serious impairment of bodily functions.	Emergency Care: Same as network coverage.
Paid-in-full benefits for chemotherapy, radiation therapy or dialysis and for pre-admission testing and/or pre-surgical testing prior to an inpatient admission.	Same as network coverage

Infertility

Network Coverage

(or) Non-Network Coverage

The following services provided in the inpatient or outpatient departments of a hospital are covered: artificial/intra-uterine insemination, inpatient and/or outpatient surgical or medical procedures, performed in the hospital, which would correct malfunction, disease or dysfunction resulting in infertility, and associated diagnostic tests and procedures including but not limited to those described in New York State Insurance Law as set forth in Chapter 82 of the Laws of 2002.

Same as network coverage.

Hospice Care

Network Coverage	(or) Non-Network Coverage
Paid-in-full benefit for up to 210 days when provided by an approved hospice program.	Plan pays up to 100 percent of allowable expenses for up to 210 days.

Medical/Surgical Coverage

UnitedHealthcare P.O. Box 1600, Kingston, New York 12402-1600

United HealthCare benefits are paid under either the Network or Non-Network Coverage. Some medically necessary services are paid in full; others are subject to copayment or to a 15-visit per person limit. Note: Any visits you make to your campus Student Health Center, which is not a network provider, do not count toward the 15-visit per person limit or network dollar maximum. Call the Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and choose United HealthCare if you have questions about your medical/surgical coverage.

Network Coverage

(or) Non-Network Coverage

Some covered services received from a network provider are paid-in-full and others are subject to a copayment as described below. The Plan does not guarantee that participating providers are available in all specialties or geographic locations. To learn whether a provider participates, check with the provider directly, call United HealthCare or refer to the list on this site. Always confirm the provider's participation before you receive services.

Annual Deductible: $100 per covered individual. Coinsurance: Plan pays 80 percent of allowable expenses for covered services after you meet the annual deductible.

Inpatient in a Hospital or Birthing Center

Network Coverage	(or) Non-Network Coverage
Covered services received from a network provider while you are an inpatient are paid in full and do not count toward the 15-visit per person limit.	Non-network benefits for covered services by a non-network provider.
Paid-in-full benefit for pre-admission testing and/or pre-surgical testing prior to an inpatient admission, radiology, anesthesiology and pathology.	Same as network coverage.

Outpatient Department of a Hospital

Network Coverage	(or) Non-Network Coverage
Paid-in-full benefits for covered outpatient services provided in the outpatient department of a hospital by a network provider.	Non-network benefits for covered services by a non-network provider.
For medical emergency: paid in full benefits for attending emergency room physician and providers who administer or interpret radiological exams, laboratory tests, electrocardiogram and pathology services when these services are not covered by Empire BlueCross BlueShield. Services of other physicians are considered under network coverage or non-network coverage as appropriate.	Same as network coverage.
Paid-in-full benefit for pre-admission testing and/or pre-surgical testing prior to an inpatient admission, chemotherapy, anesthesiology, radiology, pathology or dialysis when not covered by Empire BlueCross BlueShield; does not count toward 15-visit per person limit.	Plan pays up to 100 percent of allowable expenses.
Medically necessary physical therapy covered under the Managed Physical Medicine Program when not covered by Empire BlueCross BlueShield.	Non-network coverage under the Managed Physical Medicine Program when not covered by Empire BlueCross BlueShield.

Doctor's Office Visit, Office Surgery, Laboratory and Radiology

Network Coverage	(or) Non-Network Coverage
You have network coverage for up to 15 visits per person per calendar year to a participating provider, subject to a $10 copayment per visit. The copayment includes diagnostic laboratory tests and radiology done during the office visit. The following types of office visits and services are paid in full and do not count toward the 15-visit per person limit: hemodialysis, chemotherapy and radiation therapy, well-child care, prenatal and postnatal office visits included in your provider's delivery charge. Prenatal and postnatal office visits that are not included in the delivery charge are subject to a $10 copayment but do not count toward 15-visit per person limit. Diagnostic laboratory tests and radiology not performed during an office visit, including interpretation of mammograms and analysis of cervical cytology screening, are covered subject to a $10 copayment and do not count toward the 15-visit per person limit.	Non-network benefits for covered services received from non-participating providers or after the 15th visit to a participating provider.
$10 copayment for contraceptive drugs and devices that require injection, insertion or other physician intervention and are provided during an office visit. (This copayment is in addition to your $10 copayment for the office visit.)	Contraceptive drugs and devices: Same as network coverage, subject to deductible and coinsurance.
Infertility treatment: $10 copayment for covered services such as artificial/intra-uterine insemination provided during an office visit. MRIs require prior authorization. Outpatient surgery visits are not subject to copayment but count toward 15-visit per person limit.	Infertility treatment: Same as network coverage, subject to deductible and coinsurance.
Second surgical opinion: $10 copayment for one out-of-hospital specialist consultation in each specialty field per condition per calendar year; counts toward 15-visit per person limit. One paid-in-full in-hospital consultation in each field per confinement.	Second surgical opinion: Same as network coverage, subject to deductible and coinsurance.
$10 copayment for a second medical opinion by an appropriate specialist in the event of a positive or negative diagnosis of cancer or recurrence of cancer or a recommendation of course of treatment for cancer.	Second opinion for cancer diagnosis: Same as network coverage.

Routine Health Exams

Network Coverage	(or) Non-Network Coverage
Same as non-network coverage.	Routine physical: Up to $60 reimbursement once every two years for active employee under age 40; annually for active employee over age 40. Not subject to copayment or 15-visit per person limit or deductible. There is no coverage for routine health exams for a spouse/domestic partner.

Allergy Care

Network Coverage	(or) Non-Network Coverage
Office visits are covered subject to a $10 copayment and count toward 15-visit per person limit. No separate copayment for basic skin tests done during office visit. Tests provided on different date or different location require a separate $10 copayment, but do not count toward 15-visit per person limit.	Not Covered

Routine Well-Child Care

Network Coverage	(or) Non-Network Coverage
Paid-in-full benefit for children up to age 19 including examinations and immunizations administered pursuant to pediatric guidelines. Well-child care visits do not count toward the 15-visit per person limit.	Plan pays 100 percent of allowable expenses. This benefit is not subject to deductible or coinsurance.

Mammograms and Cervical Cytology Screening

Network Coverage	(or) Non-Network Coverage
$10 copayment for mammography received from a network provider following recommended guidelines. $10 copayment for cervical cytology screening. (Also see Hospital Outpatient.)	Plan pays 80 percent of allowable expenses after you meet the annual deductible.

Pregnancy Termination

Network Coverage	(or) Non-Network Coverage
Paid-in-full benefit; does not count toward 15-visit per person limit.	Plan pays 80 percent of allowable expenses after you meet the annual deductible.

Ambulatory Surgical Center

Network Coverage	(or) Non-Network Coverage
$10 copayment covers facility, same-day on-site testing and anesthesiology charges for covered services at a participating surgical center.	Non-network benefits for covered services provided by non-participating surgical centers.

Ambulance Service

Network Coverage	(or) Non-Network Coverage
Plan pays for local commercial ambulance charges for emergency transportation, subject to a $15 copayment.
Emergency transportation is covered when the service is provided by a licensed ambulance service to the nearest hospital where emergency care can be performed and ambulance transportation is required because of an emergency condition.	Emergency transportation is covered the same as network coverage. This benefit is not subject to deductible or coinsurance.
Non-emergency transportation is covered the same as non-network coverage.	Non-emergency transportation is covered if it is medically necessary and provided by a licensed ambulance service. The Plan pays 80% of allowable expenses after you meet the annual deductible.

Enteral Formulas; Modified Solid Food Product

Network Coverage	(or) Non-Network Coverage
Same as non-network coverage.	For prescribed enteral formulas, Plan pays up to 80 percent after you meet the annual deductible. For certain prescribed modified solid food products, Plan pays up to 80 percent after you meet the annual deductible, up to a total maximum reimbursement of $2,500 per covered person per calendar year.

Managed Physical Medicine Program (MPN)

Chiropractic Treatment and Physical Therapy

(When you use MPN) Network Coverage

(or) (When you don't use MPN) Non-Network Coverage

You pay a $10 copayment for each office visit to a Managed Physical Network provider. You pay an additional $10 copayment for related radiology and diagnostic laboratory services billed by the MPN provider. Chiropractic Treatment: Up to 15 visits per person per calendar year. Physical Therapy: Up to 60 visits per diagnosis, if determined by MPN to be medically necessary. Access to network benefits is guaranteed for chiropractic treatment and physical therapy. If there is not a network provider in your area, call the Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and choose United HealthCare's MPN.

Annual Deductible: $100 per covered individual. This deductible is separate from other plan deductibles. Coinsurance: Plan pays up to 80 percent of allowable expenses after you meet the annual deductible. Non-network benefits for covered services received from non-network providers, or after the 15th chiropractic visit per year, or after the 60th physical therapy visit per diagnosis, by a network provider.

Program requirements apply even if another health insurance plan (including Medicare) is primary.

Home Care Advocacy Program (HCAP)

Home Care Services in Lieu of Hospitalization and Diabetic Equipment/Supplies

(When you use HCAP) Network Coverage	(or) (When you don't use HCAP) Non-Network Coverage
for prior authorization
Home care services provided in lieu of hospitalization are paid in full for 365 visits. To receive this benefit, you must call the Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose United HealthCare's Home Care Advocacy Program (HCAP) for prior authorization.	Home care not covered unless pre-certified. If pre-certified, Plan pays 80 percent of allowable expenses after you meet the annual deductible.
Diabetic equipment and supplies, including insulin pumps and Medijectors are paid in full. To receive diabetic equipment and supplies, (except insulin pumps andMedijectors) call The Empire Plan Diabetic Supplies Pharmacy at 1-888-306-7337. For insulin pumps andMedijectors you must call the Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose United HealthCare's HCAP for prior authorization and use a network provider.	Diabetic equipment and supplies are covered up to 100 percent of allowable expenses; not subject to deductible and coinsurance.

Program requirements apply even if another health insurance plan (including Medicare) is primary.

Mental Health and Substance Abuse Program

ValueOptions (administrator for GHI) P.O. Box 778, Troy, New York 12181-0778

Pre-certification required. Call the plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose ValueOptions (administrator for GHI) before seeking any treatment for mental health or substance abuse, including alcoholism.

ValueOptions' Clinical Referral Line is available 24 hours a day, every day of the year. By following the Program requirements for network coverage, you will receive the highest level of benefits. Access to network benefits is guaranteed.

In an emergency, ValueOptions will either arrange for an appropriate provider to call you back (usually within 30 minutes) or direct you to an appropriate facility for treatment. In a life-threatening situation, go to the emergency room. If you are admitted as an inpatient, you or someone acting on your behalf must call ValueOptions within 48 hours.

Program requirements apply even if another health insurance plan (including Medicare) is primary.

Only treatment determined medically necessary by ValueOptions is covered.

If you are in treatment for mental health or alcohol/substance abuse at the time your NYSHIP SEHP coverage begins, please contact ValueOptions for help in making the transition to your NYSHIP coverage.

Mental Health Facility

Network Coverage

(or) Non-Network Coverage

Mental Health Care in an Approved General Acute or Psychiatric Hospital or Clinic: Inpatient and Partial Hospitalization, Intensive Outpatient and Day Treatment Programs, 23 Hour Extended and 72 Hour Crisis Beds. Copayment: $200 per person per admission; new copayment required if admission occurs more than 90 days after the previous admission. Coverage level: The Plan pays up to 100 percent (50 percent if elective care is not pre-certified) of the network allowance after you pay the copayment. Mental Health Care in a Residential Treatment Center, Group Home or Halfway House. Coverage for up to 30 days per person per year in an approved facility. $200 copayment per admission; new copayment required if admission occurs more than 90 days after the previous admission. Coverage level: Plan pays up to 80 percent (50 percent if elective care is not pre-certified) of the network allowance after the copayment. You pay the remaining balance.

Mental Health Care in an Approved General Acute or Psychiatric Hospital or Clinic: Inpatient and Partial Hospitalization, Intensive Outpatient and Day Treatment Programs, 23 Hour Extended and 72 Hour Crisis Beds. Copayment: $200 per person per admission; new copayment required if admission occurs more than 90 days after the previous admission. Coverage level: The Plan pays 80 percent (50 percent if elective care is not pre-certified) of ValueOptions' reasonable and customary amount after you pay the copayment. You pay the remaining balance. Mental Health Care in a Residential Treatment Center, Group Home or Halfway House. Not a covered benefit.

Inpatient Alcohol/Substance Abuse

Network Coverage	(or) Non-Network Coverage
The Plan covers up to 7 days for detoxification under the hospital benefit. No coverage for inpatient alcohol/substance abuse treatment.	Same as network benefits.

Outpatient Mental Health

Network Coverage	(or) Non-Network Coverage
Network coverage for up to 15 visits per person per calendar year to a network practitioner, subject to a $10 copayment per visit. You pay the copayment. For visits 16 and beyond, non-network outpatient coverage applies.	Non-network benefits for covered services received from non-network practitioners or after the 15th visit to a network practitioner. Annual Deductible: $100 per covered individual: Plan pays 80% of ValueOptions' reasonable and customary amount for covered services after the deductible. You pay the deductible and the remaining balance. The annual deductible is separate from the medical deductible.
Hospital emergency room: You pay a $25 copayment (waived if you are admitted as an inpatient directly from the emergency room.)	Hospital emergency room: Same as network benefits.

Outpatient Alcohol/Substance Abuse

Network Coverage	(or) Non-Network Coverage
100 percent of allowable expenses, less your $10 copayment per visit for medically necessary pre-certified care (20 visits annually available for family members).When multiple visits per week are pre-certified, only 2 copayments will apply.	Plan pays 100 percent of allowable expenses, less your $10 copayment, for non-network visits. Coverage for up to 60 visits annually (20 of which can be used by family members). If not pre-certified, Plan pays 50 percent of allowable expenses, less your $10 copayment.

Prescription Drug Program

Jointly administered by Empire BlueCross BlueShield and Caremark –

The Empire Plan Prescription Drug Program P.O. Box 11826, Albany, New York 12211

Benefit Maximum

$2,500 per person annual maximum for prescription drugs (network and non-network combined)

Copayments

You have the following copayments for drugs purchased from a participating pharmacy or through the Mail Service pharmacy.

Up to a 30-day supply from a participating retail pharmacy or through the Mail Service
Generic Drug $5
Preferred Brand-Name Drug $15
Non-Preferred Brand-Name Drug $30

31- to 90-day supply only through the Mail Service
Generic Drug $5
Preferred Brand-Name Drug $20
Non-Preferred Brand-Name Drug $55

If you choose to purchase a brand-name drug which has a generic equivalent, you will pay the non-preferred brand-name drug copayment plus the difference in cost between the brand-name drug and the generic, not to exceed the full cost of the drug. Certain drugs are excluded from this requirement. You pay only the applicable copayment for these brand-name drugs with generic equivalents: Coumadin, Dilantin, Lanoxin, Levothroid, Mysoline, Premarin, Synthroid and Tegretol. You have coverage for prescriptions for more than a 30-day supply only at the mail service pharmacy. Oral contraceptives are covered as brand or generic. Prescriptions may be refilled for up to one year.

Preferred Drug List

See your Health Benefits Administrator (HBA) or visit our website for a copy of the 2007 Empire Plan Preferred Drug List (PDL), which applies to your Plan. It is not a complete list of all drugs covered under the SEHP but represents the most commonly prescribed generic and brand-name drugs. The PDL offers alternatives that are safe and effective equivalents to higher cost drugs. Medically necessary non-preferred brand-name drugs that are not on the PDL are covered, but at a higher cost to you and subject to the annual maximum.

Alphabetic order and therapeutic class order versions of the 2007 PDL are both available on the website at www.cs.state.ny.us. Click on Benefit Programs, then NYSHIP Online and choose GSEU, if prompted. The lists are available under Health Benefits.

Mail Service Pharmacy

You may fill your prescription through the mail service by using a mail service envelope. To obtain a mail service envelope, call the Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Prescription Drug Program. To refill a prescription on file with the Mail Service pharmacy, you may order by phone at this number or refer to the information on this site.

Non-Network Pharmacy

If you do not use an Empire Plan network pharmacy, you must submit a claim to the Prescription Drug Program. If your prescription was filled with a generic drug or a brand-name drug with no generic equivalent, you will be reimbursed up to the amount the program would reimburse a network pharmacy for that prescription. If your prescription was filled with a brand-name drug that has a generic equivalent, you will be reimbursed up to the amount the program would reimburse a network pharmacy for filling the prescription with that drug's generic equivalent. In most cases, you will not be reimbursed the total amount you paid for the prescription.

Prior Authorization Required

Certain prescription drugs require prior authorization.

This list is subject to change as drugs are approved by the Food and Drug Administration and introduced into the market. For the most current list of drugs requiring prior authorization, call the Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Prescription Drug Program or refer to the information on this site (choose Benefit Programs then NYSHIP Online, and choose your group, if prompted). For information about prior authorization requirements, call the Prescription Drug Program at the number above.

Note: At Campus Student Health Centers at University at Buffalo and Stony Brook, you are able to fill prescriptions for a $7 copayment for up to a 30-day supply.

Exclusions

Services not covered under the SEHP include, but are not limited to, the following:

• expenses in excess of $100,000 (non-network benefits); in excess of $350,000 (network and non-network combined); and prescription drugs in excess of $2,500 (network and non-network combined);
• care that is not medically necessary;
• experimental or investigative procedures;
• custodial care;
• cosmetic surgery;
• routine foot care;
• reversal of sterilization;
• assisted reproductive technology and other infertility services (except artificial/intra-uterine insemination and other services for which coverage is mandated by New York State Insurance Law); sex change; cloning;
• durable medical equipment and supplies unless provided under the Home Care benefit;
• prosthetics (except breast prostheses, which are paid in full);
• orthotics;
• TMJ treatment (except when caused by a medical condition);
• hearing aids;
• weight loss treatment (except for otherwise covered medical care and prescription drugs for treatment of morbid obesity);
• adult immunizations (except as part of a covered routine physical);
• skilled nursing facility care;
• allergy extracts and injections;
• inpatient alcohol and substance abuse treatment (except detoxification is covered for up to 7 days);
• psychological testing and evaluation and outpatient psychiatric second opinion;
• drugs furnished solely for the purpose of improving appearance rather than physical function or control of organic disease.

SEHP Dental Care Benefit Summary

Dental Program

Each visit is subject to a $20 copayment, up to two visits per 12 month period when you visit a participating provider in the SEHP dental program for covered services.

Covered Services

• Initial examination, including charting
• Periodic examination
• Cleaning
• Bitewing X-Rays, maximum four X-rays per year

Up to two fillings per 12 month period are covered subject to a $ 10 copayment per filling when you visit a participating provider in the SEHP dental program.

Participating Provider: To locate a participating provider in the SEHP dental program, you can link to the GHI website by accessing www.cs.state.ny.us. Choose Benefit Programs then NYSHIP Online, and choose your group, if prompted. Select Other Benefits, then Dental or call 1-800-947-0101.

GHI's Discounted Dental Access Program

When you enroll in the SEHP dental program you are automatically enrolled in GHI's Discounted Dental Access Program. If you utilize a provider who participates in the GHI Discounted Dental Access Program (and receive services other than the covered services above), you are required to pay the provider directly for all care received, and your liability is reduced to a pre-arranged discounted access rate. You are not subject to pre-certification or eligibility verification when you utilize the discounted program.

Participating Provider: To locate a participating provider in the GHI Discounted Dental Access Program, please call GHI's Dedicated Customer Service Center at 1-800-947-0101 for a list or a CD-ROM identifying GHI Discounted Dental Access Program participating providers.

Administration

For Eligibility questions, please contact the agency Health Benefits Administrator on your campus.

For Customer Service, please contact GHI's Dedicated Customer Services Center at 1-800-947-0101 after you have enrolled.

Correspondence: Please direct your correspondence to:
GHI, Attn: NYS Dental Customer Service, P.O. Box 12365, Albany, New York 12212-2365.
Please be sure to include your identification number on all correspondence.

ID Card: If you go to a provider who participates in the SEHP dental program and/or the GHI Discounted Dental Access Program, present your GHI identification card before you receive services.

SEHP Vision Care Benefit Summary

Network Benefits

A routine eye examination (subject to a $10 copayment) is covered once in any 24-month period (based on your last date of service).

A limited selection of frames and lenses or daily wear, disposable or planned replacement contact lenses offered by a participating provider at the time and place of an eye exam will be paid in full. This benefit is available only once in any 24-month period. There is no coverage for services received from a non-participating provider.

To confirm eligibility or locate a network provider

Contact EyeMed, the plan administrator, at 1-877-226-1412 or link to their website by accessing www.cs.state.ny.us. Choose Benefit Programs then NYSHIP Online, and choose your group, if prompted. Select Other Benefits, then Vision.

To receive services from a network provider

• Contact the network provider and schedule an appointment.
• Identify yourself as covered under the SEHP vision care program available through the NYS Vision Plan, which is administered by EyeMed.
• Give the provider your name and date of birth, or member ID number.

The provider will confirm your eligibility and obtain an authorization to provide services. At the time of your appointment, be sure to pay the provider your $10 eye examination copayment.

Notice of Access to Women's Health Services

This notice is provided in accordance with the NYSWomen's Health andWellness Act. Plan provides direct access to primary and preventive obstetric and gynecologic services for no fewer than two examinations annually. Plan covers services required as a result of such examinations. Plan covers services required as a result of an acute gynecologic condition. Plan covers all care related to pregnancy. Benefits for these services are paid according to the terms of Network or Non- Network coverage.

Benefits Management Program requirements apply.

Annual Notice of Mastectomy and Reconstructive Surgery Benefits

Plan covers inpatient hospital care for lymph node dissection, lumpectomy and mastectomy for treatment of breast cancer for as long as the physician and patient determine hospitalization is medically necessary. Plan covers all stages of reconstructive breast surgery following mastectomy, including surgery of the other breast to produce a symmetrical appearance. Plan also covers treatment for complications of mastectomy, including lymphedema and breast prostheses.

Benefits Management Program requirements apply.

YOUR COST

In calendar year 2007, the employee share of the biweekly premium for NYSHIP-SEHP medical/dental/vision coverage is:

Individual coverage $4.79 or
Family coverage $41.53

Biweekly paycheck deductions at the 2007 rate began automatically with the paycheck dated December 27, 2006. Rates are higher for COBRA enrollees.

2007 GSEU Rates

This document provides a brief look at SEHP medical, dental and vision care benefits. If you have questions or need claim forms, call the appropriate insurance carrier.

Teletypewriter (TTY) numbers for callers who use a TTY because of a hearing or speech disability.

Empire BlueCross BlueShield	TTY Only 1-800-241-6894
UnitedHealthcare	TTY Only 1-888-697-9054
ValueOptions	TTY Only 1-800-334-1897
The Prescription Drug Program	TTY Only 1-800-863-5488
EyeMed	TTY Only 1-800-308-2847

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