The Empire Plan is a unique health insurance plan designed especially for public employees in New York State. Empire Plan benefits include inpatient and outpatient hospital coverage, medical/surgical coverage, Centers of Excellence for transplants, infertility and cancer, home care services, equipment and supplies, mental health and substance abuse coverage and prescription drug coverage.
GOVERNOR
DEPARTMENT OF CIVIL SERVICE
ALBANY, NEW YORK 12239
www.cs.ny.gov
PA11-20
TO: Participating Agency Chief Executive Officers and Health Benefit Administrators
FROM: Robert W. DuBois, Director of the Employee Benefits Division
SUBJECT: New York State Health Insurance Program (NYSHIP) Benefit Changes for Participating Agencies
DATE: November 2, 2011
This is a summary of Empire Plan benefit changes effective January 1, 2012 for Participating Agency enrollees and their covered dependents. Please note this summary information is not intended to provide a complete description of each change. Enrollees will receive information concerning the January 1, 2012 changes in the Empire Plan at a Glance publication that will be mailed later this year.A Prescription drug formulary changes will be reflected in the 2012 Flexible Formulary Drug List which will be mailed with the Empire Plan at a Glance and will include a new group specific copayment card. Detailed information concerning these changes will be provided in the January 2012 Empire Plan Report and Certificate Amendments, which will be mailed directly to your agency’s enrollees. If enrollees have any questions concerning these benefit changes they should contact the appropriate Empire Plan program by calling 1-877-7-NYSHIP (1-877-769-7447).
Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
As a result of NYSHIP’s implementation of the requirements set forth under the MHPAEA, effective January 1, 2012, the Medical/Surgical and Mental Health Substance Abuse (MHSA) Programs will have a shared annual non-network deductible, and the Hospital, Medical/Surgical, and MHSA Programs will have a shared annual coinsurance maximum. The shared annual non-network deductible will not include the Managed Physical Medicine Program (MPN) annual non-network deductible. The MPN Program will continue to have a separate annual non-network deductible of $250 for the enrollee, $250 for the spouse/domestic partner and $250 for all dependent children combined.
Shared Annual Non-Network Deductible: The annual non-network deductible will increase to $1000 for the enrollee, $1000 for the spouse/domestic partner and $1000 for all dependent children combined.
Shared Annual Coinsurance Maximum: The annual coinsurance maximum will increase to $3000 for the enrollee, $3000 for the spouse/domestic partner and $3000 for all dependent children combined.
Medical/Surgical Program Changes
Effective January 1, 2012, Independent Nurse Practitioners and Convenience Care Clinics ("Minute Clinics") will be eligible to become participating providers. There will be no non-network coverage for these providers.
Prescription Drug Program Changes
Flexible Formulary: Effective January 1, 2012 NYSHIP will implement enhancements to the flexible formulary:
- Brand-name drugs may be placed on Level 1 and their high cost generic alternative excluded or placed on Level 3 when clinically appropriate and financially advantageous (Brand for Generic Program).
- Certain therapeutic categories may not have a brand-name drug on Level 2.
- A prescription drug may be excluded if it contains one or more active ingredients available in another covered prescription drug.
- A prescription drug may be excluded if it is a therapeutic equivalent or modified version of another covered prescription drug or over-the-counter medication.
Prescription Drug Copayments: Effective January 1, 2012, copayments for prescriptions received at a Network Retail Pharmacy, the Mail Service Pharmacy and the Specialty Pharmacy will be:
30 day Supply at Network Retail Pharmacy, Mail Service Pharmacy or Specialty Pharmacy
Level 1 or Most Generic Drugs - $5
Level 2, Preferred Brand-name Drug or Compound Drug - $25
Level 3 or Non-preferred Brand-name Drug - $45
31 to 90 day Supply at Network Retail Pharmacy
Level 1 or Most Generic Drugs - $10
Level 2, Preferred Brand-name Drug or Compound Drug - $50
Level 3 or Non-preferred Brand-name Drug - $90
31 to 90 day Supply at Mail Service Pharmacy or Specialty Pharmacy
Level 1 or Most Generic Drugs - $5
Level 2, Preferred Brand-name Drug or Compound Drug - $50
Level 3 or Non-preferred Brand-name Drug - $90
We have attached to this memo a one page summary of the 2012 NYSHIP benefit changes, which can be provided to enrollees as a supplement to the materials normally distributed during health fairs or employee information days.