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New York State Health Insurance Program
SUNY Student Employee Health Plan (SEHP) for Graduate Student Employees Union (GSEU) - January 1, 2002

For Employees of the State University of New York represented by GSEU
and for their enrolled Dependents
and for COBRA enrollees with SEHP benefits

2003 NYSHIP GSEU Rates

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 Health Benefits Administrator on your campus. For more detailed benefit information call the insurance carriers at the numbers below.

Benefit Summary

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

Hospital Benefits Program insured and administered by Empire Blue Cross and Blue Shield
518-367-0009 (Albany area and Alaska)
1-800-342-9815 (NYS and other states except Alaska)

Provides coverage for inpatient and outpatient services provided by a hospital or birthing center and 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.

Medical/Surgical Benefits Program insured and administered by UnitedHealthcare
1-800-942-4640

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.

Call 1-800-638-9918 for: Home care services provided in lieu of hospitalization, diabetic supplies provided by the Home Care Advocacy Program and Benefits Management Program services for Prospective Procedure Review for Magnetic Resonance Imaging (MRI).

Managed Mental Health and Substance Abuse Program insured by GHI and administered by ValueOptions
1-800-446-3995

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

Prescription Drug Program insured by CIGNA and administered by Express Scripts
1-800-964-1888

Provides coverage for prescription drugs, oral contraceptives and diaphragms through network pharmacies, the 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 Davis Vision
1-800-999-5431

Provides coverage for routine eye examinations and discounts on 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 $3,800 or more each contract year.
  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 $3,800 or more when annualized over each respective July 1 through June 30 contract year.
  3. A graduate student employee (and his/her dependents) currently enrolled in NYSHIP (Empire Plan or 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.

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 one year. 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% 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, who is usually located 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 (for the 2001-2002 academic year, it was August 15 through September 28, 2001)
  3. Involuntary loss of other coverage
  4. At any time, with a 30-day waiting period before coverage begins

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
  • The employee becoming a child's legal guardian, step-parent, or adoptive parent
  • The arrival of an eligible dependent in the United States
  • Completion of the one year waiting period for attainment of domestic partnership status
  • Involuntary loss of other coverage

EFFECTIVE DATES FOR NEW ENROLLMENTS

Event - New benefits-eligible appointment- application received within 45 days of appointment
Effective Date -
Date enrollment form is received in the SUNY Human Resources office, or the effective date of the appointment, whichever is later.
Exceptions:

Employees on F-1 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.

Event - Annual Open Enrollment Period (45 day period determined by SUNY)
Effective Date -
Date enrollment form is received in the SUNY Human Resources office, if received within the 45 day period

Event - Within 30 days of involuntary loss of other coverage
Effective Date -
Effective the date the enrollment form is received in the SUNY Human Resources office

Event - All Others
Effective Date -
Effective 30 days after the enrollment form is received in the SUNY Human Resources office

EFFECTIVE DATES FOR ADDITION OF DEPENDENTS

Event - Within 30 days of Qualifying Event
Effective Date -
Effective the date of event

Event - Within 30 days of involuntary loss of other coverage
Effective Date -
Effective the date the enrollment form is received in the SUNY Human Resources office

Event - All Others
Effective Date -
Effective 30 days after the enrollment form is received in the SUNY Human Resources office

Mandatory enrollment of domestic students

Domestic students at campuses where enrollment for health inssurance 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 to either obtain a health insurance waiver or to enroll in the SEHP in a timely manner may result in the employee 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 for 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.

Summer enrollment

Eligible student employees who are employed 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.

Cost

The State will contribute 90 percent of the cost of individual coverage and 75 percent of the additional cost for dependent coverage.

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.

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 request 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 Blue Cross and Blue Shield and UnitedHealthcare 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

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

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

Pre-Admission Certification

Phone

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

You must call Empire Blue Cross and Blue Shield at 518-367-0009 (Albany area and Alaska) or
1-800-342-9815 (New York State and other states except Alaska):

  • 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 Blue Cross and Blue Shield does not certify the hospitalization, the plan pays up to 50% of allowable expenses after your $200 copayment.

Prior Authorization of Magnetic Resonance Imaging (MRI)

Phone

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

You must call UnitedHealthcare at 1-800-638-9918 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 Blue Cross and Blue Shield

Empire Blue Cross and Blue Shield pays for covered services provided in an inpatient or outpatient hospital setting. UnitedHealthcare provides benefits for certain medical and surgical care when it is not covered by Empire Blue Cross and Blue Shield. Call the insurance carrier if you have questions about your benefits, coverage or an Explanation of Benefits statement.

 

Network Coverage

(or) Non-Network Coverage

Hospital Inpatient Semi-Private Room Or Birthing Center

Phone

Copayment: $200 per person per admission; new copayment required if hospitalization occurs more than 90 days after previous discharge.

Coverage level: The plan pays 80% 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.

Same as network coverage

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 covered. If you choose early discharge following delivery, you may request one paid-in-full Home Care Visit.

Same as network coverage

Hospital
Outpatient

Surgery, diagnostic radiology, mammography screening, cervical cytology screening, diagnostic laboratory tests, and administration of Desferal for Cooley's Anemia are subject to one copayment of $8 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 (see Prior Authorization of Magnetic Resonance Imaging (MRI)).

$8 copayment per visit for up to 60 visits for medically necessary physical therapy following a related hospitalization or related inpatient or outpatient surgery.

Outpatient Care: Same as network coverage, except subject to an annual deductible of $100 per covered individual.
Coinsurance: The plan pays 80% of allowable expenses after you meet the $100 deductible.

Emergency Care

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 $15 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.

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.

Emergency Care: Same as network coverage

Hospice Care

Paid-in-full benefit for up to 210 days when provided by an approved hospice program.

Plan pays up to 100% of allowable expenses



Medical/Surgical coverage

UnitedHealthcare

UnitedHealthcare 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 15-visit per person limit.

 

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 UnitedHealthcare or visit the Participating Provider Directory on the Web. Always confirm the provider's participation before you receive services.

Annual Deductible: $100 per covered individual.

Coinsurance: Plan pays 80% of allowable expenses for covered services after you meet the annual deductible.

Inpatient in a Hospital or Birthing Center

Covered services received from a network provider while you are an inpatient are paid-in-full and do not count toward 15-visit per person limit.

Non-network benefits for covered services by a non-network provider.

Outpatient Department
of a
Hospital

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.

Emergency

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 Blue Cross and Blue Shield. Services of other physicians are considered under network coverage or non-network coverage as appropriate.

Same as network coverage.

Pre-admission Testing

Paid-in-full benefit for pre-admission testing and/or pre-surgical testing prior to an inpatient admission. Paid-in-full benefit for chemotherapy, radiation therapy or dialysis when not covered by Empire Blue Cross and Blue Shield; does not count toward 15-visit per person limit.

Plan pays up to 100% of allowable expenses.

Out-Patient Physical Therapy

Medically necessary physical therapy covered under the Managed Physical Medicine Program when not covered by Empire Blue Cross and Blue Shield.

Non-network coverage under the Managed Physical Medicine Program when not covered by Empire Blue Cross and Blue Shield.

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

You have network coverage for up to 15 visits per person per calendar year to a participating provider, subject to an $8 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 $8 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 screening are covered subject to $8 copayment and do not count toward the 15-visit per person limit.

MRI's require prior authorization (see Prior Authorization of Magnetic Resonance Imaging (MRI)).

Outpatient surgery visits are not subject to copayment but count toward 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.

Second Surgical Opinion

Second surgical opinion: $8 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. This includes 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 surgical opinion: Same as network coverage, subject to deductible and coinsurance.

Routine
Health Exams

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.

Allergy Care

Office visits are covered subject to $8 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 $8 copayment, but do not count toward 15-visit per person limit.

Not Covered

Routine
Well-Child Care

Paid-in-full for children up to age 19 including examinations and immunizations. Well-child care visits do not count toward the 15-visit per person limit.

Plan pays 100% of allowable expenses. This benefit is not subject to deductible or coinsurance.

Mammograms and Cervical Cytology Screening

$8 copayment for mammography received from a network provider following recommended guidelines. $8 copayment for cervical cytology screening. (Also see Outpatient Hospital.)

Plan pays 80% of allowable expenses after you meet the annual deductible.

Pregnancy Termination

Paid-in-full, does not count toward 15-visit per person limit.

Plan pays 80% of allowable expenses after you meet the annual deductible.

Ambulatory
Surgical Center

$8 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

Same as non-network coverage

Plan pays up to $300 per year for local professional ambulance charges. This benefit is not subject to deductible or coinsurance.

Enteral Formula

Same as non-network coverage

For prescribed enteral formula, Plan pays up to 80% after you meet the annual deductible. For certain prescribed modified solid food products, Plan pays up to 80% after you meet the annual deductible, up to a maximum of $2,500.



Managed Physical Medicine Program (MPN)

 

(When you use MPN)
Network Coverage

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

Chiropractic Treatment and Physical Therapy

You pay an $8 copayment for each office visit to a Managed Physical Network provider. You pay an additional $8 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. Contact MPN if there is not a network provider in your area.

Annual Deductible: $100 per covered individual. This deductible is separate from other plan deductibles.

Coinsurance: Plan pays up to 80% 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)

 

(When you use HCAP)
Network Coverage

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

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

Phone

Home care services provided in lieu of hospitalization are paid-in-full for 365 visits. To receive this benefit, you must call the Home Care Advocacy Program (HCAP) at 1-800-638-9918 for prior authorization.

Diabetic equipment and supplies, including insulin pumps and Medijectors are paid-in-full. To receive diabetic equipment and supplies, (except insulin pumps and Medijectors) call National Diabetic Pharmacies at 1-888-306-7337. For insulin pumps and Medijectors you must call HCAP at 1-800-638-9918 for prior authorization and use a network provider.

Home care not covered unless pre-certified. If pre-certified, plan pays 80% of allowable expenses after you meet the deductible.

 

Diabetic equipment and supplies are covered up to 100% 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

Phone

Pre-certification required. Call ValueOptions (administrator for GHI) at 1-800-446-3995 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. Then, you 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 currently in treatment for mental health or alcohol/substance abuse, please contact ValueOptions for help in making the transition to your NYSHIP coverage.

 

Network Coverage

(or) Non-Network Coverage

Inpatient
Mental Health

Coverage for up to 30 days per person per year (Combined network/non-network maximum). $200 copayment per admission.

After you pay the copayment, Plan pays up to 80% (50% if you do not receive prior authorization for services) of the network allowance. You pay copayment and remaining balance.

Same as network benefits if pre-certified. If not pre-certified, plan pays 50% of allowable expenses.

Inpatient Alcohol/ Substance Abuse

The Plan covers up to 7 days for detoxification under the hospital benefit (see Inpatient and Outpatient Hospital Coverage).

Same as network benefits

Outpatient Mental Health

Coverage for up to 30 visits per year (combined network/non-network maximum).

Visits 1-10: Plan pays 50% of allowable expenses up to $50 per visit

Visits 11-30: Plan pays 50% of allowable expenses up to $35 per visit

If pre-certified, coverage for up to 30 visits per year (combined network/non-network maximum).

Visits 1-30: Plan pays 50% of allowable expenses up to $25 per visit

Outpatient Alcohol/Substance Abuse

100% of allowable expenses, less your $8 copayment per visit for medically necessary pre-certified care (20 visits annually available for family members).

Plan pays 100% of allowable expenses, less your $8 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% of allowable expenses, less your $8 copayment.



PRESCRIPTION DRUG PROGRAM

Benefit Maximum

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

Network Pharmacy

At a network pharmacy, you have a $6 copayment for a generic drug and a $10 copayment for a brand-name drug with no generic equivalent. If you choose to purchase a brand-name drug which has a generic equivalent, you will pay the $10 copayment plus the difference in cost between the brand and the generic. Certain drugs are excluded from this requirement. You pay only the $10 copayment for these 10 brand-name drugs with generic equivalents: Coumadin, Dilantin, Lanoxin, Levothroid, Mysoline, Premarin, Slo-Bid, Synthroid, Tegretol and Theo-Dur. $10 copayment for diaphragms.

Oral contraceptives are covered as brand or generic. One copayment covers up to a 30-day supply. Prescriptions may be refilled for up to one year. No coverage for Norplant or Depo Provera.

No generic appeals process.

Mail Service Pharmacy

You may fill your prescription through the mail service by using a mail service envelope. The same copayments and rules for generic drugs apply as if you were using a network pharmacy. To obtain a mail service envelope, call Express Scripts. To refill a prescription on file with the Express Scripts Mail Service pharmacy, you may order by phone at 1-800-964-1888 or online at http://www.express-scripts.com.

Non-Network Pharmacy

If you do not use a network pharmacy, you must submit a claim to Express Scripts. 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.

Phone

You must call Express Scripts at 1-800-964-1888 for prior authorization for the following drugs:

  • BCG Live
  • Cerezyme
  • Drugs for the treatment of impotency
  • Enbrel
  • Epoetin
  • Human Growth Hormone
  • Immune Globulin
  • Lamisil
  • Prolastin
  • Pulmozyme
  • Sporanox

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) for prescription drugs;
  • care that is not medically necessary;
  • experimental or investigative procedures;
  • cosmetic surgery;
  • routine foot care;
  • reversal of sterilization;
  • infertility services (except the diagnosis and treatment of correctable medical conditions) and assisted
    reproductive technology;
  • 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);
  • nursing home care;
  • allergy extracts and injections;
  • inpatient alcohol and substance abuse (except 7 days of detoxification);
  • custodial care;
  • psychological testing and evaluation and outpatient psychiatric second opinion

SEHP DENTAL Care Benefit Summary
Effective July 1, 2001

Dental Benefits

Subject to a $20 copayment per visit. Maximum 2 visits per year only when you visit a participating provider in the GSEU Dental Program.

Examinations

  • Initial examination, including charting
  • Periodic examination
  • Cleaning

Bitewing X-Rays

  • Maximum 4 x-rays per year

Other Services

  • You will be enrolled in GHI's Discounted Access Program. When you use a GHI Participating Provider that accepts this program, your out-of-pocket expenses will be limited to the GHI Schedule of Allowance.
  • For Eligibility questions, please contact the agency Health Benefits Administrator on your campus.
  • For Customer Service, please call GHI's Dedicated Customer Service 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.
  • You can access the GHI Web site at www.ghi.com to find a participating provider.

SEHP Vision Care Benefit Summary

Benefit Maximum

A routine eye examination (subject to an $8 copayment) is covered every two years (based on your last date of service). You are also eligible to receive up to a $40 reimbursement toward the discounted cost of your eyeglasses and/or contact lens materials, dispensed in conjunction with your covered exam. Additional fees for contact lens fitting are not covered.

Network Provider Location

At a network provider, you pay an $8 copayment toward the cost of your eye examination and you may purchase eyeglasses and/or contact lenses (in conjunction with your eye examination) subject to the following discounts:

Eyeglass frames and/or spectacle lenses: Usual and customary fee, less 25%
Special spectacle lens types and/or coatings: Usual and customary fee, less 25%
Standard contact lens types: Usual and customary fee, less 20%
Disposable contact lens types: Usual and customary fee, less 10%

Non-network Provider Location

The services described above (eye examination, materials, reimbursement) are only covered at a
network provider.

To confirm eligibility or locate a network provider

Contact Davis Vision, the plan administrator, at 1-800-999-5431 or visit their Web site at www.davisvision.com.

To receive services from a network provider

  • Contact the network provider and schedule an appointment
  • Identify yourself as covered under the GSEU vision care program which is administered by
    Davis Vision
  • Give the provider your name and 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 $8 eye examination copayment and all fees related to the purchase of eye wear. The provider will advise you of the discounted charges that apply.

Claiming Reimbursement

To claim reimbursement of material expenses up to the defined maximum ($40), complete and submit a Vision Care Direct Reimbursement Claim Form. Claim forms are available by calling Davis Vision at 1-800-999-5431 or visiting their Web site at www.davisvision.com.

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.

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

Empire Blue Cross and Blue Shield TTY Only 1-800-241-6894

UnitedHealthcare TTY Only 1-888-697-9054

ValueOptions TTY Only 1-800-334-1897

Express Scripts TTY Only 1-800-840-7879

Davis Vision TTY Only 1-800-523-2847

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