the new york state health insurance program … quarters/hq...empire state plaza, core building 1,...

Empire State Plaza, Core Building 1, Albany, NY 12239│ www.cs.ny.gov

ANDREW M. CUOMO Governor

The New York State Health Insurance Program (NYSHIP) for Employees of Participating Employers Welcome to the New York State Health Insurance Program (NYSHIP). As a new employee, or an employee newly eligible for health insurance, there are some important things you should know:

You may select coverage under The Empire Plan or, if offered by your employer, a NYSHIP HMO. Refer to the Choices guide for a comprehensive overview of each option.

Federal Health Care Reform requires that a Summary of Benefits and Coverage be available for each NYSHIP option available to you. You may view copies of each at https://www.cs.ny.gov/sbc. Or, if you do not have internet access, you may call 1-877-7-NYSHIP (1-877-769-7447) and choose the Medical Program to request a copy for The Empire Plan. Contact the HMOs directly for printed copies of their SBCs.

Your Health Benefits Administrator (HBA) – usually located in your agency’s personnel office, is the person you should contact to make any changes to your health insurance coverage. For example, if you need to add or remove a dependent, update your address, change your health insurance option, or if you have any questions about your coverage, contact your HBA.

Check NYSHIP Online at https://www.cs.ny.gov/employee-benefits for updates and information, including new publications, your prescription drug list, benefit changes and to find a participating provider.

If you enroll in a NYSHIP HMO, you may want to familiarize yourself with their web site and bookmark it for your reference and use.

PE New Employee Letter/SBC Attach/2016

Individual Family Individual Family

001 NYS EMPIRE PLAN (All States) $36.08 $172.54 $37.39 $178.36

310CDPHP

(Dutchess, Orange and Ulster counties)$43.24 $200.97 $44.19 $204.82

220

HIP ( Formerly GHI-HMO (Upstate))

(Albany, Columbia, Greene, Rensselaer, Saratoga, Schenectady,

Warren & Washington)

$48.50 $220.14 $53.21 $241.30

350HIP ( Formerly GHI HMO Select)

(Delaware, Dutchess, Orange, Putnam, Sullivan & Ulster)$48.50 $220.14 $53.21 $241.30

050

HIP of New York

(Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk &

Westchester)

$43.97 $199.21 $46.83 $211.80

060

MVP Health Plan - East

(Albany, Columbia, Fulton, Greene, Hamilton, Montgomery,

Rensselaer, Saratoga, Schenectady, Schoharie, Warren &

Washington)

$33.57 $143.04 $35.58 $151.62

330

MVP Health Plan- Central

(Broome, Cayuga, Chenango, Cortland, Delaware, Herkimer,

Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, Otsego,

Tioga & Tompkins)

$38.29 $164.72 $40.43 $173.73

340MVP Health Plan- Mid Hudson

(Dutchess, Orange, Putnam, Rockland, Sullivan & Ulster)$37.71 $162.41 $40.12 $173.37

333ConnectiCare - Command Staff only**

(Connecticut only)$44.99 $219.31 $44.31 $216.02

280Empire BlueCross BlueShield HMO - Upstate

(Columbia, Greene, Rensselaer, Schenectady & Warren)$41.30 $202.63

290

Empire BlueCross BlueShield HMO- Downstate

(Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland,

Suffolk & Westchester)

$55.97 $276.41

320Empire BlueCross BlueShield HMO - Mid Hudson

(Dutchess, Orange, Putnam, Sullivan & Ulster )$57.95 $286.40

Bi-Weekly Medical Insurance Contributions

MTAHQ

Management Employees (BSC, CC, IG, Police Command Staff)

NYSHIP Rates as of January 1, 2020

2019 2020

Plan no longer offered

01/01/2020


01/01/2020

PPO

HMOs

Code # PLANS


01/01/2020

Created Dec 6, 2014 Printed 12/13/2019

Health Insurance Choices for 2020

October 2019For employees of the State of New York, Participating Employers, their enrolled dependents,

COBRA enrollees with their NYSHIP benefits and Young Adult Option enrollees

New York State Department of Civil Service, Employee Benefits Division, Albany, New York 12239www.cs.ny.gov/employee-benefits

http://www.cs.ny.gov/employee-benefits

Information & RemindersMake Your Health Plan ChoicesThis booklet explains the options available to you under the New York State Health Insurance Program (NYSHIP) for your health insurance and other elections. You may choose coverage under The Empire Plan or one of the NYSHIP-approved Health Maintenance Organizations (HMOs) in your area. Or, if you can be covered under other employer-sponsored group health benefits, you may be eligible to elect the Opt-out Program.*

Consider your options carefully. You may not change your option after the deadline, except in special circumstances (see your General Information Book for details about changing options outside of the Option Transfer Period). If you still have questions after you have read the information in this booklet, contact your Health Benefits Administrator (HBA), The Empire Plan program administrators or the HMOs directly.

Rates for 2020 and Deadline for Changing PlansThe Empire Plan and HMO rates for 2020 will be mailed to your home and posted on our website, NYSHIP Online, as soon as they have been approved. To find this information online, go to www.cs.ny.gov/employee-benefits. Next, select your group and plan, if prompted, and then Health Benefits & Option Transfer. Choose Rates and Health Plan Choices.

Note: Participating Employers (PEs), such as the Thruway Authority and the Metropolitan Transportation Authority, will notify their enrollees of 2020 rates.

The rate flyer announces the option-change deadline and dates that changes in health insurance payroll deductions will occur. You will have 30 days from the date your agency receives rate information to submit any changes. Your HBA can help if you have questions. COBRA and Young Adult Option enrollees may contact the Employee Benefits Division at 518-457-5754 or 1-800-833-4344 (United States, Canada, Puerto Rico and the Virgin Islands).

* The Opt-out Program is available to eligible NYS employees who have other employer-sponsored group health insurance. Employees who are represented by UUP are not eligible to participate in this program. Check with your HBA if you have any questions about your eligibility for the Opt-out Program. PE employees should check with their HBA to determine whether their employer offers a program similar to the Opt-out Program. See page 13 for more information about this program.

ContentsInformation & Reminders i

Make Your Health Plan Choices iRates and Deadline for Changing Plans iPre-Tax Contribution Program 1Your Share of the Premium 2Let Your Agency Know About Changes 2If You Retire or Leave State Service in 2020 2If You Become Eligible for Medicare in 2020 2

Medicare & NYSHIP 3Comparing Your NYSHIP Options 4

Benefits 4Exclusions 4Geographic Area Served 4Finding Providers/Hospitals in Your Network 4

The Empire Plan or a NYSHIP HMO 5What’s New? 5The Empire Plan 5NYSHIP HMOs 6Summary of Benefits and Coverage 6NYSHIP’s Young Adult Option 6

Benefits Overview 7Making a Choice 8

Things to Remember 9If You Decide to Change Your Option 9How to Use the Choices Benefits Charts 9

Plan Similarities and Differences 10-11Questions & Answers 12Opt-out Program 13Plans by County 14-15Empire Plan Benefits 16-25NYSHIP HMO Benefits 26-39NYSHIP Online 40-41

i Choices 2020/Active


Changing Your 2020 Pre-Tax Contribution Program (PTCP) StatusPTCP does not apply to COBRA and Young Adult Option enrollees. The following also may not apply to enrollees of Participating Employers (PEs). PEs that participate in a pre-tax contribution program will provide specific pre-tax information to their employees.

Under PTCP, your share of the health insurance premium is deducted from your wages before taxes are withheld, which may lower your tax liability.

If you wish to change your PTCP election for 2020, complete and sign a NYS Health Insurance Transaction Form (PS-404) and submit it to your HBA any time during the PTCP Election Period.

New in 2020: The PTCP Election Period will now run concurrently with the Option Transfer Period. Dates will be announced once rates have been approved.

NO ACTION IS REQUIRED TO KEEP YOUR CURRENT PTCP STATUS.

Checking Your PTCP Status Your paycheck shows whether or not you are enrolled in PTCP.

• If you are enrolled in PTCP, your paycheck stub shows “Regular Before-Tax Health” in the Before-Tax Deductions section. Your health insurance premium is deducted from your wages before taxes are withheld.

• If you are not enrolled in PTCP, or part of your deduction is being taken after tax (e.g., for a non-federally qualifying dependent), your paycheck stub shows “Regular After-Tax Health” in the After-Tax Deductions section. Your health insurance premium is deducted from your wages after taxes are withheld.

New Enrollees When enrolling in NYSHIP coverage, new enrollees must elect whether or not to participate in PTCP. No election will be made automatically on the enrollee’s behalf. Enrollment cannot be completed without a PTCP election.

PTCP Enrollment Limits Mid-Year ChangesInternal Revenue Service (IRS) rules do not allow enrollees to change their PTCP election outside of the annual Election Period. However, if you experience a PTCP qualifying event that leads you to change your

health option or coverage type (Family or Individual) or to cancel your coverage, your pre-tax payroll deduction will be adjusted accordingly. Any request to change your benefits during the tax year must be consistent with a PTCP qualifying event and submitted within 30 days of the event.

PTCP qualifying events include:

• Change in marital status• Change in number of dependents (the event must

affect the eligibility of all covered dependents)• Change in your (or your dependent’s) employment

status that affects eligibility for health benefits• Change in your dependent’s status that affects

eligibility for health benefits• Change in your (or your dependent’s) place

of residence or worksite that affects eligibility for benefits

• Significant change in health benefits and/or premium under NYSHIP

• Significant change in health benefits and/or premium under your (or your dependent’s) other employer’s plan

• COBRA events• Judgment, decree or order to provide health

benefits to eligible dependents• Medicare or Medicaid eligibility• Leaves of absence• HIPAA special enrollment rights

A coverage change due to a PTCP qualifying event must be requested within 30 days of the event (or within the waiting period if newly eligible); delays may be costly.

See your HBA to change your health insurance option, type of coverage or pre-tax status

NO ACTION IS REQUIRED IF YOU DO NOT WISH TO MAKE CHANGES

Note: It is no longer necessary to reenroll in the Opt-out Program each year See page 13 for a detailed description of this option

Remember, changes are not automatic, and deadlines apply You must report any change that may affect your coverage to your HBA See pages 1-2 of this book and your General Information Book for more information

1Choices 2020/Active

Your Share of the PremiumThe following does not apply to employees of Participating Employers (PEs will provide premium information), COBRA enrollees, Young Adult Option enrollees or enrollees in Leave Without Pay status (who pay the full cost of coverage).

New York State helps pay for your health insurance coverage. After the State’s contribution, you are responsible for paying the balance of your premium, usually through biweekly deductions from your paycheck.

Whether you enroll in The Empire Plan or a NYSHIP HMO, the State’s share and your share of the cost of coverage are based on the following (salary requirements vary; contact your HBA for more information):

Enrollee Pay GradeIndividual Coverage Dependent Coverage

State Share Employee Share State Share Employee Share

Grade 9 and below* 88% 12% 73% 27%

Grade 10 and above* 84% 16% 69% 31%

* Or salary equivalent, if no Grade assigned. Contact your HBA to confirm.

If you enroll in a NYSHIP HMO, the State’s dollar contribution for the hospital, medical/surgical and mental health and substance use components of your HMO premium will not exceed its dollar contribution for those components of The Empire Plan premium. For the prescription drug component of your HMO premium, the State pays the share noted in the table; the dollar amount is not limited by the cost of Empire Plan drug coverage.

Let Your Agency Know About ChangesYou must notify your HBA if your home address or phone number changes. If you are an active employee of New York State and registered for MyNYSHIP, you may also make address and option changes online. Note: It is now necessary to have a personal NY.gov ID to access MyNYSHIP. See page 40 for more information. MyNYSHIP is not available for active employees of PEs.

Changes in your family status, such as gaining or losing a dependent, may mean that you need to change your health insurance coverage from Individual to Family or from Family to Individual. If you submit a request within 30 days of a change in family status, you may make these changes outside of the Option Transfer Period without experiencing a break in coverage. See your General Information Book for details. Promptly inform your HBA about any change to ensure it is effective on the actual date of change in family status.

If You Retire or Leave State Service in 2020If you continue your NYSHIP enrollment as a retiree or vestee, you may change your health insurance option when your status changes. As a retiree or vestee, you may change your health insurance option at any time once during a 12-month period. For more information on changing options as a retiree or vestee, ask your HBA for a copy of 2020 Choices for Retirees.

If You Become Eligible for Medicare in 2020If you or a dependent is eligible for Medicare because of age or disability, refer to the Medicare & NYSHIP section on page 3 for important information. Please read this section if you or any dependent will be turning 65 in 2020 or if you are planning to retire in the coming year and will become Medicare primary.

2 Choices 2020/Active

If you are an active employee, NYSHIP provides primary coverage for you and your dependents, regardless of age or disability. Exceptions: Medicare is primary for domestic partners age 65 or older or for an active employee or dependent of an active employee with end-stage renal disease (following a 30-month coordination period).

NYSHIP requires you and your dependents to be enrolled in Medicare Parts A and B when first eligible for Medicare coverage that pays primary to NYSHIP. If you or a dependent are eligible for but don’t enroll in Medicare Parts A and B, The Empire Plan or HMO will not provide benefits for services Medicare would have paid if you or your dependent had enrolled.

If you are planning to retire or vest in 2020 and you or your spouse are 65 or older, contact your Social Security office three months before active employment ends to enroll in Medicare Parts A and B. Medicare becomes primary to your NYSHIP coverage the first day of the month following a “runout” period of 28 days after the end of the payroll period in which you retire. Make sure to take the time to learn how primary Medicare coverage will affect NYSHIP:

• If you are enrolled in original Medicare (Parts A and B) and The Empire Plan: The Empire Plan coordinates benefits with Medicare Parts A and B. Because Medicare does not provide coverage outside the United States, The Empire Plan pays primary for covered services received outside the United States.

• If you are enrolled in a NYSHIP HMO that coordinates coverage with Medicare: You receive the same benefits from the HMO as active employees do and also qualify for original Medicare benefits if you receive services not covered by your HMO.

• If you are enrolled in a NYSHIP HMO’s Medicare Advantage Plan (Part C): You replace your original Medicare coverage with benefits offered by the Medicare Advantage Plan. The plan also includes Medicare Part D prescription drug benefits. Benefits and networks under the HMO’s Medicare Advantage Plan may differ from your coverage as an active employee.

Note: Medicare allows enrollment in only one Medicare product at a time. Therefore, enrolling in a Medicare Advantage Plan, a Medicare Part D plan or another Medicare product (including those in which you or your covered dependents may be enrolled through another employer) in addition to your NYSHIP coverage will result in the cancellation of your NYSHIP coverage.

Medicare Part D is the prescription drug benefit for Medicare-primary individuals. Medicare-primary Empire Plan enrollees and dependents are enrolled automatically in Empire Plan Medicare Rx, a Part D prescription drug program. NYSHIP Medicare Advantage HMOs also provide Medicare Part D prescription drug coverage. Remember, if you enroll in a Medicare Part D plan separate from your NYSHIP coverage, you will be automatically disenrolled from your NYSHIP Plan. For example:

• If you are a Medicare-primary Empire Plan enrollee or dependent with prescription drug coverage through Empire Plan Medicare Rx and then you enroll in another Medicare Part D plan outside of NYSHIP, the Centers for Medicare & Medicaid Services (CMS) will terminate your Empire Plan Medicare Rx coverage. Because you must be enrolled in Empire Plan Medicare Rx to maintain Empire Plan coverage, you and your covered dependents will lose all coverage under The Empire Plan.

• If you are enrolled in a NYSHIP HMO’s Medicare Advantage Plan and then enroll in a Medicare Part D plan outside of NYSHIP, CMS will terminate your enrollment in the HMO.

If you have been approved for Extra Help by Medicare and you are enrolled in The Empire Plan or a NYSHIP Medicare Advantage HMO, you may be reimbursed for some or all of your cost for Medicare Part D coverage. For information about qualifying for Extra Help, contact Medicare. If you have been approved for Extra Help, contact the Employee Benefits Division or your HMO.

If you receive prescription drug coverage through a union Employee Benefit Fund, contact the fund for information about Medicare Part D.

For more information about NYSHIP and Medicare, see your General Information Book or ask your HBA for a copy of 2020 Choices for Retirees, Planning for Retirement or Medicare & NYSHIP.

Medicare & NYSHIP


Choosing the option that best meets your needs and the needs of your family requires careful consideration. As with most important purchases, there is more to consider than cost.

The first step toward making a good choice is understanding the similarities and differences between your NYSHIP options. There are two types of health insurance plans available to you under NYSHIP: The Empire Plan and NYSHIP-approved HMOs. The Empire Plan is available to all employees. NYSHIP HMOs are available in various geographic areas of New York State. Depending on where you live or work, at least one HMO will be available to you.

Additionally, if you have other employer-sponsored group health coverage available to you, you may be eligible for the Opt-out Program (see page 13 for details).

BenefitsThe Empire Plan and NYSHIP HMOs• All NYSHIP plans provide a wide range of hospital,

medical/surgical and mental health and substance use coverage.

• All plans provide prescription drug coverage for those who do not receive it through a union Employee Benefit Fund.

• All plans provide coverage for certain preventive care services as required by the federal Patient Protection and Affordable Care Act (PPACA). For more information on preventive care services, visit www.hhs.gov/healthcare/rights/preventive-care (Empire Plan enrollees may also find additional information on NYSHIP Online).

Benefits differ among plans. Refer to this booklet and the Empire Plan Certificate (available from your HBA and on NYSHIP Online) and HMO contracts (available from each HMO) for details.

Exclusions• All plans contain coverage exclusions for certain

services and prescription drugs. • Workers’ compensation-related expenses and

custodial care are generally excluded from coverage.

For details on a plan’s exclusions, read the Empire Plan Certificate or the NYSHIP HMO contract, or check with the plan directly.

Geographic Area ServedThe Empire PlanBenefits for covered services, not just urgent and emergency care, are available worldwide. However, access to network benefits is not guaranteed in all states and regions.

Health Maintenance Organizations (HMOs)• Coverage is available in each HMO’s specific

service area.• An HMO may arrange for coverage of care

received outside its service area at its discretion in certain circumstances. See the out-of-area benefit description on each HMO page in this booklet for details.

Finding Providers/Hospitals in Your Network For Empire Plan provider information:• Visit NYSHIP Online at www.cs.ny.gov/employee-

benefits. Select your group and plan, if prompted, and then Find a Provider. Note: This is the most up-to-date source for provider information.

• Check with the provider/facility directly.• Call The Empire Plan toll free at 1-877-7-NYSHIP

(1-877-769-7447) and select the appropriate program for the type of provider you need.

For HMO provider information:• Visit the HMO websites (addresses are provided

on the individual HMO pages in this booklet).• Check with the provider/facility directly.• Call the telephone numbers on the HMO pages in

this booklet. Ask which providers participate and which hospitals are affiliated.

Note: You cannot change your plan outside the Option Transfer Period if your only reason for the change is that your provider no longer participates.

Comparing Your NYSHIP Options


http://www.hhs.gov/healthcare/rights/preventive-care

http://www.cs.ny.gov/employee-benefits.Select



What’s New in 2020?The Empire Plan• For 2020, the maximum out-of-pocket limit for

covered, in-network services under The Empire Plan is $8,150 for Individual coverage and $16,300 for Family coverage, split between the Hospital, Medical/Surgical, Mental Health and Substance Abuse and Prescription Drug Programs. See table below for more information about how out-of-pocket limits apply to each Empire Plan program.

• As a result of a change in policy, gender affirming surgery and any other associated surgeries, services and procedures (including those performed to change an enrollee’s physical appearance to more closely conform secondary sex characteristics to their identified gender) are now covered if a behavioral health provider determines the surgery or procedure is medically necessary. See your Empire Plan Report for more information.

NYSHIP HMOs• As of January 1, 2020, the Empire BlueCross

BlueShield HMO will no longer be offered as a NYSHIP option. If you currently have coverage under the Empire BlueCross BlueShield HMO, be sure to review your plan materials and any other related NYSHIP mailings carefully and select either The Empire Plan, a different NYSHIP HMO or the Opt-out Program during the Option Transfer Period.

The Empire PlanThe Empire Plan is a unique plan designed exclusively for New York State’s public employees. The Empire Plan has many managed-care features,

but enrollees are not required to choose a primary care physician (PCP) and do not need referrals to see specialists. However, certain services, such as hospital and skilled nursing facility admissions, certain outpatient radiological tests, certain mental health and substance use treatment/services, home care and some prescription drugs, require preapproval.

The Empire Plan is self-insured, and the New York State Department of Civil Service contracts with qualified companies to administer the Plan.

ProvidersUnder The Empire Plan, you can choose from more than 300,000 participating physicians and other providers and facilities nationwide and from more than 65,000 participating pharmacies across the United States or a mail service pharmacy.

Some licensed nurse practitioners and convenience care clinics participate with The Empire Plan. Be sure to confirm participation before receiving care.

Under the Guaranteed Access benefit, The Empire Plan provides access to network benefits for covered services provided by PCPs and certain specialists when you are Empire Plan primary and do not have access to a network provider within a reasonable distance from your residence. This benefit is available in New York State and specific counties in Connecticut, Massachusetts, New Jersey, Pennsylvania and Vermont that share a border with New York State. Note: This benefit does not apply to enrollees of Participating Employers.

2020 Empire Plan Maximum Out-of-Pocket Limits for In-Network Services

Coverage Type Prescription Drug Program*

Hospital, Medical/Surgical and Mental Health

and Substance Abuse Programs, Combined

Total

Individual Coverage $2,850 $5,300 $8,150

Family Coverage $5,700 $10,600 $16,300

* Does not apply to Medicare-primary enrollees or Medicare-primary dependents.

The Empire Plan or a NYSHIP HMO


NYSHIP Health Maintenance OrganizationsA health maintenance organization (HMO) is a managed-care system in a specific geographic area that provides comprehensive health care coverage through a network of providers.

• Coverage for services received outside the specified geographic area is limited. HMO enrollees who use doctors, hospitals or pharmacies outside the HMO’s network must, in most cases, pay the full cost of services unless authorized by the HMO or in an emergency.

• Enrollees usually choose a PCP from the HMO’s network for routine medical care and for referrals to specialists and hospitals when medically necessary.

• HMO enrollees usually pay a copayment as a per-visit fee or coinsurance (percentage of cost).

• HMOs have no annual deductible. • Referrals to network specialists may be required. • Claim forms are rarely required.

NYSHIP HMOs are organized in one of two ways:• A network HMO provides medical services through

its own health centers, as well as through outside participating physicians, medical groups and multispecialty medical centers.

• An Independent Practice Association (IPA) HMO provides medical services through private practice physicians who have contracted independently with the HMO to provide services in their offices.

A member enrolling in either a network or IPA model HMO may be able to select a doctor he or she already uses if that doctor participates with the HMO.

See the individual HMO pages in this booklet for additional benefit information and to learn which HMOs serve your geographic area.

NYSHIP HMOs and MedicareIf you are Medicare eligible, see page 3 for an explanation of how Medicare affects your NYSHIP HMO coverage.

Summary of Benefits and CoverageThe Summary of Benefits and Coverage (SBC) is a standardized comparison document required by the Patient Protection and Affordable Care Act.

To view a copy of an SBC for The Empire Plan or a NYSHIP HMO, visit www.cs.ny.gov/sbc. If you do not have internet access, call 1-877-7-NYSHIP (1-877-769-7447) and select the Medical/Surgical Program to request a copy of the SBC for The Empire Plan. If you need an SBC for a NYSHIP HMO, contact the HMO.

NYSHIP’s Young Adult OptionThis option allows unmarried, young adult children (up to age 30) of NYSHIP enrollees to purchase their own NYSHIP coverage During the Option Transfer Period, eligible adult children of NYSHIP enrollees can enroll in the Young Adult Option and current Young Adult Option enrollees are able to switch plans The premium is the full cost of Individual coverage for the NYSHIP option selected

For more information about the Young Adult Option, go to www cs ny gov/yao and select the young adult’s parent’s employer group From your group-specific page, you can download enrollment forms, review plan materials and compare rates for The Empire Plan and all NYSHIP HMOs

This site is your best resource for information on NYSHIP’s Young Adult Option If you have additional questions, please contact the Employee Benefits Division at 518-457-5754 or 1-800-833-4344


http://www.cs.ny.gov/yao

http://www.cs.ny.gov/sbc

Benefits OverviewThe Empire Plan provides: • Network and non-network inpatient and

outpatient hospital coverage for medical, surgical and maternity care

• Center of Excellence Programs for cancer, transplants and infertility

• 24-hour Empire Plan NurseLineSM for health information and support

• Worldwide coverage

Each NYSHIP HMO provides:• Inpatient and outpatient hospital care at a

network hospital• A specific package of health services, including

hospital, medical, surgical and preventive care benefits, provided or arranged by the PCP selected by the enrollee from the HMO’s network

All plans provide:• Inpatient medical/surgical

hospital care• Outpatient medical/surgical

hospital services• Physician services• Emergency care*• Laboratory services• Radiology services• Chemotherapy• Radiation therapy• Dialysis• Diagnostic services• Diabetic supplies• Maternity, prenatal care• Well-child care• Chiropractic services• Skilled nursing facility services• Physical therapy• Occupational therapy

• Speech therapy• Prosthetics and durable

medical equipment• Orthotic devices• Medically necessary bone

density tests• Mammography• Inpatient mental health services• Outpatient mental health services • Alcohol and substance

use detoxification• Inpatient alcohol rehabilitation • Inpatient drug rehabilitation • Outpatient alcohol and

drug rehabilitation • Family planning and certain

infertility services• Out-of-area emergencies• Hospice benefits (at least 210 days)• Home health care in lieu

of hospitalization

• Prescription drug coverage, including injectable and self-injectable medications, vaccines, contraceptive drugs and devices and fertility drugs (unless you have coverage through a union Employee Benefit Fund)

• Enteral formulas covered through either The Empire Plan’s Home Care Advocacy Program (HCAP) or the NYSHIP HMO’s prescription drug program (unless you have coverage through a union Employee Benefit Fund)

• Second opinion for cancer diagnosis

• Gender affirming care• In vitro fertilization (up to 3 cycles)• Fertility preservation

Please see the individual plan descriptions in this booklet to determine the differences in coverage and out-of-pocket expenses. See plan documents for complete information on benefits.

* Some plans may exclude coverage for air ambulance services. Call The Empire Plan or your NYSHIP HMO for details.


Selecting a health insurance plan is an important and personal decision. Only you know your family’s lifestyle, health, budget and benefit preferences. Think about what health care you and your covered dependents might need during the next year. Review the plans, and ask for more information. Here are several questions to consider:

• What is my premium for the health plan?• What benefits does the plan have for office visits and

other medical care? What is my share of the cost?• What benefits does the plan have for prescription

drugs? Will the medicine I take be covered under the plan? What is my share of the cost? What type of formulary does the plan have? Can I use the mail service pharmacy? (If you receive your drug coverage from a union Employee Benefit Fund, ask the fund about your benefits.)

• Are routine office visits and urgent care covered for out-of-area college students, or is only emergency health care covered?

• Does the plan cover special needs? How are durable medical equipment and other supplies covered? Are there any benefit limitations? (If you or one of your dependents has a medical or mental health/substance use condition requiring specific treatment or other special needs, check the coverage carefully. Don’t assume you will have coverage. Ask The Empire Plan program administrators or HMOs about your specific treatment.)

• What benefits are available for a catastrophic illness or injury?

• What choice of providers do I have under the plan? (Ask if the provider or facilities you use are covered.) How would I consult a specialist if I needed one? Would I need a referral?

• How much paperwork is required by the health plan? Do I have to fill out forms?

Making a Choice


Things to Remember• Gather as much information as possible• Consider your and your family’s unique needs• Compare the coverage and cost of your options• Look for a health plan that provides the best

balance of cost and benefits for you

If You Decide to Change Your OptionIf you have reviewed the coverage and cost of your options and decide to change your option, submit a completed Health Insurance Transaction Form (PS-404) to your HBA or change your option online using MyNYSHIP (if you are an active employee of a New York State agency) before the Option Transfer deadline announced in the rate flyer. Note: MyNYSHIP cannot be used to elect the Opt-out Program (see page 13).

Understanding the Benefit Information on Pages 16–39This booklet summarizes benefits available under The Empire Plan and NYSHIP HMOs The Empire Plan is available to all employees You may choose an available NYSHIP HMO based on the area in which you live or work Identify the plans that best serve your needs, and call each plan for details before you choose

All NYSHIP plans must include a minimum level of benefits (see page 7) For example, The Empire Plan and all NYSHIP HMOs provide a paid-in-full benefit for medically necessary inpatient hospital care at network hospitals

Use the charts to compare plans The charts list out-of-pocket expenses and benefit limitations effective January 1, 2020 Make note of differences in coverage that are important to you and your family See plan documents for complete information on benefit limitations

To generate a side-by-side comparison of the benefits provided by each of the NYSHIP plans in your area, use the NYSHIP Plan Comparison tool, available on NYSHIP Online Go to www cs ny gov/employee-benefits and choose your group and plan, if prompted From the NYSHIP Online homepage, select Health Benefits & Option Transfer Click on Rates and Health Plan Choices and then NYSHIP Plan Comparison Select your group and the counties in which you live and work Then, check the box next to the plans you want to compare and click on Compare Plans to generate the comparison table

Note: Most benefits described in this booklet are subject to medical necessity and may involve limitations or exclusions Please refer to plan documents or call the plans directly for details



Will I be covered for medically necessary care I receive away from home?The Empire Plan:Yes. The Empire Plan provides worldwide coverage. However, access to network benefits is not guaranteed in all states and regions.

NYSHIP HMOs:With an HMO plan, you are always covered for emergency care. Some HMOs may provide coverage for urgent or routine care outside the HMO service area. Additionally, some HMOs provide coverage for college students away from home if the care is urgent or if follow-up care has been preauthorized. See the out-of-area benefit description on each HMO page for more information, or contact the HMO directly.

If I am diagnosed with a serious illness, can I see a physician or go to a hospital that specializes in my illness?The Empire Plan:Yes. You can use the specialist of your choice. If the doctor you choose participates in The Empire Plan, network benefits will apply for covered services. You have Basic Medical Program benefits for nonparticipating providers and Basic Medical Provider Discount Program benefits for nonparticipating providers who are part of the Empire Plan MultiPlan group (see page 19 for more information on the Basic Medical Provider Discount Program). Your hospital benefits will differ depending on whether you choose a network or non-network hospital (see page 11 for details).

NYSHIP HMOs:You should expect to choose a participating physician and a participating hospital. Under certain circumstances, you may be able to receive a referral to a specialist care center outside the network.

Can I be sure I will not need to pay more than my copayment when I receive medical services?The Empire Plan:Your copayment(s) should be your only expense if you receive medically necessary and covered services from a participating provider.

NYSHIP HMOs:As long as you receive medically necessary and covered services, follow HMO requirements and obtain the appropriate referral (if required), your copayment or coinsurance should be your only expense.

The Empire Plan & NYSHIP HMOs: Similarities & Differences


Can I use the hospital of my choice? The Empire Plan:Yes. You have coverage worldwide, but your benefits differ depending on whether you choose a network or non-network hospital. Your benefits are highest at network hospitals participating in the BlueCross and BlueShield Association BlueCard® PPO Program or, for mental health or substance use care, in the Beacon Health Options network.

Network hospital inpatient stays are paid in full. Network hospital outpatient and emergency care is subject to network copayments.

Non-network hospital inpatient stays are subject to 10 percent coinsurance, and non-network outpatient services are subject to the greater of 10 percent coinsurance or $75, up to the combined annual coinsurance maximum. Under the Mental Health and Substance Abuse Program, non-network hospital services are subject to 10 percent of covered charges up to the combined annual coinsurance maximum (see page 18).

NYSHIP HMOs:Except in an emergency, you generally do not have coverage at non-network hospitals unless authorized by the HMO.

What kind of physical therapy, occupational therapy and chiropractic care is available?The Empire Plan:You have guaranteed access to unlimited, medically necessary care when you follow Plan requirements.

NYSHIP HMOs:Coverage is available for a specified number of days/visits each year when you follow the HMO’s requirements.

What if I need durable medical equipment, medical supplies or home nursing? The Empire Plan:You have guaranteed, paid-in-full access to medically necessary home care, equipment and supplies* through the Home Care Advocacy Program (HCAP) when preauthorized and arranged by the Plan.

NYSHIP HMOs:Benefits are available, vary depending on the HMO and may require a greater percentage of cost sharing.

* Diabetic shoes have an annual maximum benefit of $500.Note: These responses are generic and highlight only general differences between The Empire Plan and NYSHIP HMOs. Details for each plan are available on individual plan pages beginning on page 16 of this booklet, in the Empire Plan Certificate (available online or from your HBA) and in the HMO contracts (available from each HMO).


Q: Can I join The Empire Plan or any NYSHIP-approved HMO?A: The Empire Plan is available regardless of where you live or work. To enroll or continue enrollment in a

NYSHIP-approved HMO, you must live or work in that HMO’s service area. See your General Information Book for details. See Plans by County on pages 14 and 15 and the individual HMO pages in this booklet to check the counties each HMO will serve in 2020.

Q: I have a preexisting condition. Will I have coverage if I change options?A: Yes. Under NYSHIP, you can change your option and still have coverage for a preexisting condition. There are

no preexisting condition exclusions in any NYSHIP plan. However, coverage and exclusions differ. Ask the plan you are considering about coverage for your condition.

Q: What if I retire in 2020 and become eligible for Medicare?A: Regardless of which option you choose, as a retiree, you and your dependent (if applicable) must be

enrolled in Medicare Parts A and B when either of you first becomes eligible for primary Medicare coverage (see page 3). Please note that your NYSHIP benefits will become secondary to Medicare and that your benefits may change.

Q: I am a COBRA dependent in a Family plan. Can I switch to Individual coverage and select a different health plan than the rest of my family?

A: Yes. As a COBRA dependent, you may elect to change to Individual coverage in a plan different from the enrollee’s Family coverage. During the Option Transfer Period, you may enroll in The Empire Plan or choose any NYSHIP-approved HMO in the area where you live or work.

Q: I elected the Opt-out Program in 2019. Can I switch to NYSHIP health coverage for 2020?A: Yes. All plan options are available during the Option Transfer Period (see Making a Choice on page 8).

Questions & Answers

Consider CostWhen considering cost, think about all your costs throughout the year, not just your biweekly paycheck deduction Keep in mind any out-of-pocket expenses you are likely to incur during the year, such as copayments for prescriptions and other services, coinsurance and any costs of using providers or services not covered under the plan Watch for the NYSHIP Rates & Deadlines for 2020 flyer that will be mailed to your home and posted on NYSHIP Online, www cs ny gov/employee-benefits, as soon as rates have been approved (Note: Participating Employers will provide premium information to their employees ) Along with this booklet, which includes copayment information, NYSHIP Rates & Deadlines for 2020 will provide the details you need to determine your annual cost under each of the available plans



The Opt-out Program is available to eligible employees who have other employer-sponsored group health coverage. If eligible, you may opt out of NYSHIP coverage in exchange for an incentive payment. The State Opt-out Program is not available to employees of Participating Employers (PEs); however, a PE may offer a similar option.

The annual incentive payment is $1,000 for opting out of Individual coverage or $3,000 for opting out of Family coverage. The incentive payment is prorated and credited through your biweekly paycheck throughout the year (payable only when you are eligible for NYSHIP coverage at the employee share of the premium). Note: Opt-out incentive payments increase your taxable income.

It is no longer necessary to reenroll in the Opt-out Program each year. No action is required for current Opt-out enrollees who are still eligible and wish to remain in the Program for the 2020 plan year.

Eligibility RequirementsTo be eligible for the Opt-out Program, you must:

• Have been enrolled in the Opt-out Program for the prior plan year or enrolled in a NYSHIP health plan by April 1, 2019 (or on your first date of NYSHIP eligibility if that date is later than April 1), and

• Remain continuously enrolled while eligible for the employee share of the premium through the end of 2019.

To qualify for the Opt-out Program, you must be covered under an employer-sponsored group health insurance plan through other employment of your own or a plan that your spouse, domestic partner or parent has as a result of his or her employment. New York State employees cannot opt out of NYSHIP if they are covered under NYSHIP as a dependent through another New York State employee.

According to NYSHIP rules, an individual cannot be enrolled in more than one NYSHIP option in his or her own right. Since the Opt-out Program is considered a NYSHIP option, an individual cannot opt out through one employer and be enrolled in NYSHIP health benefits in his or her own right through another employer.

If the employee is covered as a dependent on another NYSHIP policy through a local government or public entity, he or she is only eligible for the Individual Opt-out incentive amount ($1,000).

Find out whether the other employer-sponsored plan will permit you to enroll as a dependent. You are responsible for making sure that your other coverage is in effect during the period you opt out of NYSHIP.

Note: Opt-out Program participation satisfies NYSHIP enrollment requirements at the time of your retirement. The Opt-out Program is not available to retirees.

Electing to Opt OutIf you are currently enrolled in The Empire Plan or a NYSHIP HMO and wish to participate in the Opt-out Program, you must elect to opt out during the annual Option Transfer Period and attest to and provide information regarding your other employer-sponsored group health benefits for the next plan year.

To elect the Opt-out Program, you must complete a NYS Health Insurance Transaction Form (PS-404) and an Opt-out Attestation Form (PS-409) and submit both to your HBA. Your NYSHIP coverage will terminate at the end of the current plan year, and the incentive payments will begin with the first pay period affecting coverage for 2020.

Once enrolled in the Opt-out Program, you are not eligible for the incentive payment during any period that you do not meet the requirements for the State contribution to the cost of your NYSHIP coverage. Additionally, if you are receiving the opt-out incentive for Family coverage and your last dependent loses NYSHIP eligibility, you will only be eligible for the Individual payment from that date forward.

Reminder: If you are currently enrolled in the Opt-out Program, you may remain there or choose other NYSHIP coverage for 2020 during the Option Transfer Period.

The Opt-out Program NYSHIP Code #700


The Empire Plan is available to all enrollees in the New York State Health Insurance Program (NYSHIP) regardless of where you live or work. Coverage is worldwide.

Many NYSHIP enrollees have a choice among HMOs. You may enroll or continue to be enrolled in any NYSHIP-approved HMO that serves the area where you live or work. You may not be enrolled in an HMO outside your area. This list shows which HMOs are available in each county. Medicare-primary NYSHIP HMO enrollees will be enrolled in their HMO’s Medicare Advantage Plan, except where noted below.

Albany: CDPHP (063), HIP* (220), MVP (060) Erie: BCBS of Western New York (067), Independent Health (059)

Allegany: BCBS of Western New York (067), Independent Health (059) Essex: CDPHP (300), HMOBlue (160), MVP (360)

Bronx: HIP (050) Franklin: HMOBlue (160), MVP (360)

Broome: CDPHP (300), HMOBlue (072), MVP (330) Fulton: CDPHP (063), HMOBlue (160), MVP (060)

Cattaraugus: BCBS of Western New York (067), Independent Health (059)

Genesee: BCBS of Western New York (067), Independent Health (059), MVP (058)

Cayuga: HMOBlue (072), MVP (330) Greene: CDPHP (063), HIP* (220), MVP (060)

Chautauqua: BCBS of Western New York (067), Independent Health (059) Hamilton: CDPHP (300), HMOBlue (160), MVP (060)

Chemung: HMOBlue (072) Herkimer: CDPHP (300), HMOBlue (160), MVP (330)

Chenango: CDPHP (300), HMOBlue (160), MVP (330) Jefferson: HMOBlue (160), MVP (330)

Clinton: HMOBlue (160), MVP (360) Kings: HIP (050)

Columbia: CDPHP (063), HIP* (220), MVP (060) Lewis: HMOBlue (160), MVP (330)

Cortland: HMOBlue (072), MVP (330) Livingston: BlueChoice (066), MVP (058)

Delaware: CDPHP (310), HIP* (350), HMOBlue (160), MVP (330) Madison: CDPHP (300), HMOBlue (160), MVP (330)

Dutchess: CDPHP (310), HIP* (350), MVP (340) Monroe: BlueChoice (066), MVP (058)

* This HMO does not offer a Medicare Advantage Plan in this county but instead coordinates coverage with Medicare for Medicare-primary enrollees. For more information about how primary Medicare coverage affects NYSHIP, see page 3 and/or ask your HBA for a copy of 2020 Choices for Retirees.

Plans by County


* This HMO does not offer a Medicare Advantage Plan in this county but instead coordinates coverage with Medicare for Medicare-primary enrollees. For more information about how primary Medicare coverage affects NYSHIP, see page 3 and/or ask your HBA for a copy of 2020 Choices for Retirees.

Montgomery: CDPHP (063), HMOBlue (160), MVP (060) Schenectady: CDPHP (063), HIP* (220), MVP (060)

Nassau: HIP (050) Schoharie: CDPHP (063), MVP (060)

New York: HIP (050) Schuyler: HMOBlue (072)

Niagara: BCBS of Western New York (067), Independent Health (059) Seneca: Blue Choice (066), MVP (058)

Oneida: CDPHP (300), HMOBlue (160), MVP (330) St. Lawrence: HMOBlue (160), MVP (360)

Onondaga: HMOBlue (072), MVP (330) Steuben: HMOBlue (072), MVP (058)

Ontario: Blue Choice (066), MVP (058) Suffolk: HIP (050)

Orange: CDPHP (310), HIP* (350), MVP (340) Sullivan: HIP* (350), MVP (340)

Orleans: BCBS of Western New York (067), Independent Health (059), MVP (058) Tioga: CDPHP (300), HMOBlue (072), MVP (330)

Oswego: HMOBlue (072), MVP (330) Tompkins: HMOBlue (072), MVP (330)

Otsego: CDPHP (300), HMOBlue (160), MVP (330) Ulster: CDPHP (310), HIP* (350), MVP (340)

Putnam: HIP* (350), MVP (340) Warren: CDPHP (063), HIP* (220), MVP (060)

Queens: HIP (050) Washington: CDPHP (063), HIP* (220), MVP (060)

Rensselaer: CDPHP (063), HIP* (220), MVP (060) Wayne: Blue Choice (066), MVP (058)

Richmond: HIP (050) Westchester: HIP (050), MVP (340)

Rockland: MVP (340) Wyoming: BCBS of Western New York (067), Independent Health (059), MVP (058)

Saratoga: CDPHP (063), HIP* (220), MVP (060) Yates: Blue Choice (066), MVP (058)


Empire Plan benefits are available worldwide, and the Plan gives you the freedom to choose a participating or nonparticipating provider or facility. This section summarizes benefits available under each portion of The Empire Plan as of January 1, 2020.1 You may also visit www.cs.ny.gov/employee-benefits or call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) for additional information on the following programs.

Medical/Surgical Program UnitedHealthcare

Medical and surgical coverage through:

• Participating Provider Program – More than 300,000 physicians and other providers participate; certain services are subject to a $25 copayment.

• Basic Medical Program – If you use a nonparticipating provider, the Program considers up to 80 percent of usual and customary charges for covered services after the combined annual deductible is met. After the combined annual coinsurance maximum is met, the Plan considers up to 100 percent of usual and customary charges for covered services. See Cost Sharing (beginning on page 18) for additional information.

• Basic Medical Provider Discount Program – If you are Empire Plan primary and use a nonparticipating provider who is part of the Empire Plan MultiPlan group, your out-of-pocket costs may be lower (see page 19).

Home Care Advocacy Program (HCAP) – Paid-in-full benefits for home care, durable medical equipment and certain medical supplies (including diabetic and ostomy supplies), enteral formulas and diabetic shoes. (Diabetic shoes have an annual maximum benefit of $500.) Prior authorization is required. Guaranteed access to network benefits nationwide. Limited non-network benefits available (see the Empire Plan Certificate for details).

Managed Physical Medicine Program – Chiropractic treatment, physical therapy and occupational therapy through a Managed Physical Network (MPN) provider are subject to a $25 copayment. Unlimited network benefits when medically necessary. Guaranteed access to network benefits nationwide. Non-network benefits available.

Under the Benefits Management Program, you must call the Medical/Surgical Program for Prospective Procedure Review before an elective (scheduled) magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computerized tomography (CT) scan, positron emission tomography (PET) scan or nuclear medicine test, unless you are having the test as an inpatient in a hospital (see the Empire Plan Certificate for details).

When arranged by the Medical/Surgical Program, a voluntary, paid-in-full specialist consultant evaluation is available. Voluntary outpatient medical case management is available to help coordinate services for catastrophic and complex cases.

Hospital ProgramEmpire BlueCross

The following benefit levels apply for covered services received at a BlueCross and BlueShield Association BlueCard® PPO network hospital:

• Inpatient hospital stays are covered at no cost to you.• Outpatient hospital and emergency care are subject

to network copayments.• Anesthesiology, pathology and radiology provider

charges for covered hospital services are paid in full under the Medical/Surgical Program (if The Empire Plan provides your primary coverage).

1 These benefits are subject to medical necessity and to limitations and exclusions described in the Empire Plan Certificate and Certificate Amendments.

The Empire Plan NYSHIP Code #001

Note: Employees represented by C-82, PBANYS and PEF should refer to the companion publication entitled Health Insurance Choices for 2020 Supplement in place of pages 16-25 of this book for information about 2020 Empire Plan benefits, including copayments, coinsurance and deductibles



• Certain covered outpatient hospital services provided at network hospital extension clinics are subject to outpatient hospital copayments.

• Except as noted above, physician charges received in a hospital setting will be paid in full if the provider is a participating provider under the Medical/Surgical Program. Physician charges for covered services received from a non-network provider will be paid in accordance with the Basic Medical portion of the Medical/Surgical Program.

If you are an Empire Plan-primary enrollee,2 you will be subject to 10 percent coinsurance for inpatient stays at a non-network hospital. For outpatient services received at a non-network hospital, you will be subject to the greater of 10 percent coinsurance or $75 per visit. In either scenario, expenses will be reimbursed only after the applicable combined annual coinsurance maximum threshold (see page 19) has been reached.

The Empire Plan will approve network benefits for hospital services received at a non-network facility if:

• Your hospital care is emergency or urgent• No network facility can provide the medically

necessary services• You do not have access to a network facility

within 30 miles of your residence• Another insurer or Medicare provides your

primary coverage (pays first)

Preadmission Certification RequirementsUnder the Benefits Management Program, if The Empire Plan is your primary coverage, you must call the Hospital Program for certification of any of the following inpatient stays:

• Before a maternity or scheduled (nonemergency) hospital admission

• Within 48 hours or as soon as reasonably possible after an emergency or urgent hospital admission

• Before admission or transfer to a skilled nursing facility

If you do not follow the preadmission certification requirement for the Hospital Program, you must pay:

• A $200 hospital penalty if it is determined any portion was medically necessary; and

• All charges for any day’s care determined not to be medically necessary.

Voluntary inpatient medical case management is available to help coordinate services for catastrophic and complex cases.

Mental Health and Substance Abuse ProgramBeacon Health Options Inc.

The Mental Health and Substance Abuse (MHSA) Program offers both network and non-network benefits.

Network Benefits(unlimited when medically necessary)

If you call the MHSA Program before you receive services and follow their requirements, you receive:

• Inpatient services, paid in full• Crisis intervention, paid in full for up to three visits

per crisis; after the third visit, the $25 copayment per visit applies

• Outpatient services, including office visits, home-based or telephone counseling and nurse practitioner services, for a $25 copayment per visit

• Intensive Outpatient Program (IOP) with an approved provider for mental health or substance use treatment for a $25 copayment per day

Non-Network Benefits3

(unlimited when medically necessary)

The following applies if you do NOT follow the requirements for network coverage.

• For Practitioner Services: The MHSA Program will consider up to 80 percent of usual and customary charges for covered outpatient practitioner services after you meet the combined annual deductible per enrollee, per enrolled spouse or domestic partner

2 If Medicare or another plan provides primary coverage, you receive network benefits for covered services at both network and non-network hospitals.

3 You are responsible for ensuring that MHSA Program certification is received for care obtained from a non-network practitioner or facility.


and per all enrolled dependent children combined. After the combined annual coinsurance maximum is reached per enrollee, per enrolled spouse or domestic partner and per all enrolled dependent children combined, the Program pays up to 100 percent of usual and customary charges for covered services (see page 19).

• For Approved Facility Services: You are responsible for 10 percent of covered, billed charges up to the combined annual coinsurance maximum per enrollee, per enrolled spouse or domestic partner and per all enrolled dependent children combined. After the coinsurance maximum is met, the Program pays 100 percent of billed charges for covered services (see page 19).

• Outpatient treatment sessions for family members of an individual being treated for alcohol or substance use are covered for a maximum of 20 visits per year for all family members combined.

Empire Plan Cost SharingPlan ProvidersUnder The Empire Plan, benefits are available for covered services when you use a participating or nonparticipating provider. However, your share of the cost of covered services depends on whether the provider you use participates in the Plan. You receive the maximum plan benefits when you use participating providers. For more information, read Reporting On Network Benefits. You can find this publication at www.cs.ny.gov/employee-benefits or ask your HBA for a copy.

If you use an Empire Plan participating or network provider or facility, you pay a copayment for certain services. Some services are covered at no cost to you. The provider or facility files the claim and is reimbursed by The Empire Plan.

You are guaranteed access to network benefits for certain services when you contact the program before receiving services and follow program requirements for:

• Mental Health and Substance Abuse (MHSA) Program services

• Managed Physical Medicine Program services (physical therapy, chiropractic care and occupational therapy)

• Home Care Advocacy Program (HCAP) services (including durable medical equipment)

If you use a nonparticipating provider or non-network facility, benefits for covered services are subject to a deductible and/or coinsurance.

2020 Annual Maximum Out-of-Pocket LimitYour maximum out-of-pocket expenses for in-network covered services will be $5,300 for Individual coverage and $10,600 for Family coverage for Hospital, Medical/Surgical and MHSA Programs, combined. Once you reach the limit, you will have no additional copayments.

Combined Annual DeductibleFor Medical/Surgical and MHSA Program services received from a nonparticipating provider or non-network facility, The Empire Plan has a combined annual deductible that must be met before covered services under the Basic Medical Program and non-network expenses under both the HCAP and MHSA Programs can be reimbursed. See the table on page 19 for 2020 combined annual deductible amounts. The Managed Physical Medicine Program has a separate $250 deductible per enrollee, $250 per enrolled spouse/domestic partner and $250 per all dependent children combined that is not included in the combined annual deductible.

After you satisfy the combined annual deductible, The Empire Plan considers 80 percent of the usual and customary charge for the Basic Medical Program and non-network practitioner services for the MHSA Program, 50 percent of the network allowance for covered services for non-network HCAP services and 90 percent of the billed charges for covered services for non-network approved facility services for the MHSA Program. You are responsible for the remaining 20 percent coinsurance and all charges in excess of the usual and customary charge for Basic Medical Program and non-network practitioner services, 10 percent for non-network MHSA-approved facility services and the remaining 50 percent of the network allowance for covered, non-network HCAP services.



Combined Annual Coinsurance MaximumThe Empire Plan has a combined annual coinsurance maximum that must be met before covered services under the Basic Medical Program and non-network expenses under both the HCAP and MHSA Programs can be reimbursed. See the table below for 2020 combined annual coinsurance maximum amounts.

After you reach the combined annual coinsurance maximum, you will be reimbursed up to 100 percent of covered charges under the Hospital Program and 100 percent of the usual and customary charges for services covered under the Basic Medical Program and MHSA Program. You are responsible for paying the provider and will be reimbursed by the Plan for covered charges. You are also responsible for paying all charges in excess of the usual and customary charge.

The combined annual coinsurance maximum will be shared among the Basic Medical Program and non-network coverage under the Hospital Program and MHSA Program. The Managed Physical Medicine Program and HCAP do not have a coinsurance maximum.

Basic Medical Provider Discount ProgramIf you are Empire Plan primary, The Empire Plan also includes a program to reduce your out-of-pocket costs when you use a nonparticipating provider. The Empire Plan Basic Medical Provider Discount Program offers discounts from certain physicians and providers who are not part of The Empire Plan participating provider network. These providers are part of the nationwide MultiPlan group, a provider organization contracted with UnitedHealthcare. Empire Plan Basic Medical Program provisions apply, and you must meet the combined annual deductible.

Providers in the Basic Medical Provider Discount Program accept a discounted fee for covered services. Your 20 percent coinsurance is based on the lower of the discounted fee or the usual and customary charge. Under this Program, the provider submits your claims, and UnitedHealthcare pays The Empire Plan portion of the provider fee directly to the provider if the services qualify for the Basic Medical Provider Discount Program. Your explanation of benefits, which details claims payments, shows the discounted amount applied to billed charges.

2020 Combined Annual Deductible and Annual Coinsurance Maximum Amounts

Employees who are Management/Confidential; represented by CSEA, DC-37, NYSCOPBA, PBA,

PIA or UUP; judges, justices and nonjudicial employees of UCS; and Legislature

Combined Annual Deductible

Combined Annual Coinsurance Maximum

Enrollee $1,250 $3,750 Enrolled spouse/domestic partner $1,250 $3,750 Dependent children combined $1,250 $3,750

Reduced amount for enrollees1 in titles equated to Salary Grade 6 and below2 $625 $1,875

Reduced amount for enrollees1 represented by UUP who earn less than $37,891 $625 $1,875

1 And each deductible or coinsurance maximum amount for an enrolled spouse/domestic partner and dependent children combined.

2 This reduction does not apply to judges or justices.


To find a provider in the Empire Plan Basic Medical Provider Discount Program, ask if the provider is an Empire Plan MultiPlan provider or call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447), choose the Medical/Surgical Program and ask a representative for help. You can also go to www.cs.ny.gov/employee-benefits. Select your group and plan, if prompted, and then Find a Provider.

Prescription Drug ProgramCVS Caremark

The Prescription Drug Program does not apply to those who have drug coverage through a union Employee Benefit Fund.

• When you use a network pharmacy, the mail service pharmacy or the specialty pharmacy for a 1- to 30-day supply of a covered drug, you pay a $5 copayment for Level 1 or most generic drugs; a $30 copayment for Level 2, preferred drugs or compound drugs; and a $60 copayment for Level 3, certain generic drugs or non-preferred drugs.

• For a 31- to 90-day supply of a covered drug through a network pharmacy, you pay a $10 copayment for Level 1 or most generic drugs; a $60 copayment for Level 2, preferred drugs or compound drugs; and a $120 copayment for Level 3, certain generic drugs or non-preferred drugs.

• For a 31- to 90-day supply of a covered drug through the mail service pharmacy or the specialty pharmacy, you pay a $5 copayment for Level 1 or most generic drugs; a $55 copayment for Level 2, preferred drugs or compound drugs; and a $110 copayment for Level 3, certain generic drugs or non-preferred drugs.

• When you fill a prescription for a covered brand-name drug that has a generic equivalent, you pay the Level 3 or non-preferred copayment, plus the difference in cost between the brand-name drug and the generic equivalent (or “ancillary charge”), not to exceed the full retail cost of the drug, unless the brand-name drug has been placed on Level 1 of the Advanced Flexible Formulary. Exceptions apply. Please contact the Empire Plan Prescription Drug Program toll free at 1-877-7-NYSHIP (1-877-769-7447) for more information.

• The Empire Plan has a flexible formulary (Advanced Flexible Formulary) that excludes certain prescription drugs from coverage.

• Prior authorization is required for certain drugs.• Oral chemotherapy drugs for the treatment of

cancer do not require a copayment. • Tamoxifen and Raloxifene, when prescribed for the

primary prevention of breast cancer, do not require a copayment. In addition, generic oral contraceptive drugs/devices or brand-name drugs/devices without a generic equivalent (single-source brand-name drugs/devices) do not require a copayment. The copayment waivers for these drugs will only be provided if the drug is filled at a network pharmacy.

• Certain preventive adult vaccines, when administered at a pharmacy that participates in the CVS Caremark National Vaccine Network, do not require a copayment.

• A pharmacist is available 24 hours a day, seven days a week to answer questions about your prescriptions.

• You can use a non-network pharmacy or pay out of pocket at a network pharmacy (instead of using your Empire Plan Benefit Card) and submit a claim form for reimbursement. In almost all cases, you will not be reimbursed the total amount you paid for the prescription and your out-of-pocket expenses may exceed the usual copayment amount. To reduce your out-of-pocket expenses, use your Empire Plan Benefit Card whenever possible.

See the Empire Plan Certificate or contact the Plan for more information.

2020 Annual Maximum Out-of-Pocket Limit*Your annual maximum out-of-pocket expenses for covered drugs received from a network pharmacy will be $2,850 for Individual coverage and $5,700 for Family coverage. Once you reach the limit, you will have no additional copayments for prescription drugs.

* The annual maximum out-of-pocket limit does not apply to Empire Plan Medicare Rx.





Specialty PharmacyCVS Caremark Specialty Pharmacy is the designated pharmacy for The Empire Plan Specialty Pharmacy Program. The Program provides enhanced services to individuals using specialty drugs (such as those used to treat complex conditions and those that require special handling, special administration or intensive patient monitoring). The complete list of specialty drugs included in the Specialty Pharmacy Program is available on NYSHIP Online. Go to www.cs.ny.gov/employee-benefits and choose your group and plan, if prompted. Select Using Your Benefits and then Specialty Pharmacy Drug List.

The Program provides enrollees with enhanced services that include disease and drug education; compliance, side effect and safety management; expedited, scheduled delivery of medications at no additional charge; refill reminder calls; and all necessary supplies (such as needles and syringes) applicable to the medication.

Under the Specialty Pharmacy Program, you are covered for an initial 30-day fill of most specialty medications at a retail pharmacy, but all subsequent fills must be obtained through the designated specialty pharmacy. When CVS Caremark dispenses a specialty medication, the applicable mail service copayment is charged. To get started with CVS Caremark Specialty Pharmacy, request refills or speak to a specialty-trained pharmacist or nurse, call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447). Choose the Prescription Drug Program and ask to speak with Specialty Customer Care.

Medicare-primary enrollees and dependents: If you are or will be Medicare primary in 2020, ask your HBA for a copy of 2020 Choices for Retirees for information about your coverage under Empire Plan Medicare Rx, a Medicare Part D prescription drug program.

Contact The Empire PlanFor additional information or questions on any of the benefits described here, call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and select the applicable program.

Teletypewriter (TTY) NumbersThese numbers are available to callers who use a TTY device because of a disability and are all toll free.

Medical/Surgical Program TTY only: ...................................................................1-888-697-9054Hospital Program TTY only: ....................................................................1-800-241-6894Mental Health and Substance Abuse Program TTY only: .....................................................................1-855-643-1476Prescription Drug Program TTY only: ......................................................................................................711

The Empire Plan NurseLineSM

Call The Empire Plan and press or say 5 for the NurseLineSM for health information and support

Representatives are available 24 hours a day, seven days a week



The Empire PlanFor employees of the State of New York who are Management/Confidential; represented by

CSEA, DC-37, NYSCOPBA, PBA, PIA or UUP; judges, justices and nonjudicial employees of the Unified Court System (UCS); Legislature; and their enrolled dependents, COBRA enrollees with their NYSHIP benefits and Young Adult Option enrollees.

Benefits Network Hospital Benefits1,2 Participating Provider2 Nonparticipating Provider

Office Visits2 $25 per visit Basic Medical3

Specialty Office Visits2 $25 per visit Basic Medical3

Diagnostic Services:2 Radiology $404 or $50 per outpatient visit $25 per visit Basic Medical3

Lab Tests $404 or $50 per outpatient visit $25 per visit Basic Medical3

Pathology No copayment $25 per visit Basic Medical3

EKG/EEG $404 or $50 per outpatient visit $25 per visit Basic Medical3

Radiation, Chemotherapy, Dialysis No copayment No copayment Basic Medical3

Women’s Health Care/ Reproductive Health:2

Screenings and Maternity-Related Lab Tests

$404 or $50 per outpatient visit $25 per visit Basic Medical3

Mammograms No copayment No copayment Basic Medical3

Pre/Postnatal Visits and Well-Woman Exams

$25 per visit Basic Medical3

Bone Density Tests $404 or $50 per outpatient visit $25 per visit Basic Medical3

Breastfeeding Services and Equipment No copayment for pre/postnatal counseling and equipment purchase from a participating provider; one double-electric breast pump per birth

External Mastectomy Prostheses No network benefit. See nonparticipating provider.

Paid-in-full benefit for one single or double prosthesis per calendar year under Basic Medical, not subject to deductible or coinsurance5

Family Planning Services2 $25 per visit Basic Medical3

Infertility Services $404 or $50 per outpatient visit6 $25 per visit; no copayment at designated Centers of Excellence6

Basic Medical3


The Empire PlanFor employees of the State of New York who are Management/Confidential; represented by

CSEA, DC-37, NYSCOPBA, PBA, PIA or UUP; judges, justices and nonjudicial employees of the Unified Court System (UCS); Legislature; and their enrolled dependents, COBRA enrollees with their NYSHIP benefits and Young Adult Option enrollees.


Office Visits2 $25 per visit Basic Medical3

Specialty Office Visits2 $25 per visit Basic Medical3

Diagnostic Services:2 Radiology $404 or $50 per outpatient visit $25 per visit Basic Medical3

Lab Tests $404 or $50 per outpatient visit $25 per visit Basic Medical3

Pathology No copayment $25 per visit Basic Medical3

EKG/EEG $404 or $50 per outpatient visit $25 per visit Basic Medical3

Radiation, Chemotherapy, Dialysis No copayment No copayment Basic Medical3

Women’s Health Care/ Reproductive Health:2

Screenings and Maternity-Related Lab Tests

$404 or $50 per outpatient visit $25 per visit Basic Medical3

Mammograms No copayment No copayment Basic Medical3

Pre/Postnatal Visits and Well-Woman Exams

$25 per visit Basic Medical3

Bone Density Tests $404 or $50 per outpatient visit $25 per visit Basic Medical3

Breastfeeding Services and Equipment No copayment for pre/postnatal counseling and equipment purchase from a participating provider; one double-electric breast pump per birth

External Mastectomy Prostheses No network benefit. See nonparticipating provider.

Paid-in-full benefit for one single or double prosthesis per calendar year under Basic Medical, not subject to deductible or coinsurance5

Family Planning Services2 $25 per visit Basic Medical3

Infertility Services $404 or $50 per outpatient visit6 $25 per visit; no copayment at designated Centers of Excellence6

Basic Medical3


Contraceptive Drugs and Devices No copayment for certain FDA-approved oral contraception methods and counseling

Basic Medical3

Inpatient Hospital Surgery No copayment7 No copayment Basic Medical3

Outpatient Surgery $754 or $95 per visit $25 per visit8 Basic Medical3

Emergency Department $904 or $100 per visit9 No copayment Basic Medical3,10

Urgent Care $404 or $50 per outpatient visit11 $30 per visit Basic Medical3

Ambulance No copayment12 $70 per trip13 $70 per trip13

Mental Health Practitioner Services $25 per visit Applicable annual deductible,80% of usual and customary; after applicable coinsurance max, 100% of usual and customary (see pages 18–19 for details)

Approved Facility Mental Health Services

No copayment 90% of billed charges; after applicable coinsurance max, covered in full (see pages 18–19 for details)

1 Inpatient stays at network hospitals are paid in full. Provider charges are covered under the Medical/Surgical Program. Non-network hospital coverage provided subject to coinsurance (see page 16).

2 Copayment waived for preventive services under the PPACA. See www.hhs.gov/healthcare/rights/preventive-care or NYSHIP Online for details. Diagnostic services require plan copayment or coinsurance.

3 See Cost Sharing (beginning on page 18) for Basic Medical information. 4 For enrollees represented by CSEA and UCS enrollees only. 5 Any single external mastectomy prosthesis costing $1,000 or more requires

prior approval. 6 Certain qualified procedures require precertification and are subject to a

$50,000 lifetime allowance. 7 Preadmission certification required.

8 In outpatient surgical locations (Medical/Surgical Program), the copayment for the facility charge is $50 per visit or Basic Medical benefits apply, depending upon the status of the center. (Check with the center or The Empire Plan program administrators.)

9 Copayment waived if admitted. 10 Attending emergency department physicians and providers who administer

or interpret radiological exams, laboratory tests, electrocardiograms and/or pathology services are paid in full. Other providers are considered under the Basic Medical Program and are not subject to deductible or coinsurance.

11 At a hospital-owned urgent care facility only. 12 If service is provided by admitting hospital. 13 Ambulance transportation to the nearest hospital where emergency care

can be performed is covered when the service is provided by a licensed ambulance service and the type of ambulance transportation is required because of an emergency situation.









The Empire PlanBenefits Network Hospital Benefits1,2 Participating Provider2 Nonparticipating Provider

Outpatient Drug/Alcohol Rehabilitation $25 per day to approved Intensive Outpatient Program

Applicable annual deductible, 80% of usual and customary; after applicable coinsurance max,100% of usual and customary (see pages 18–19 for details)

Inpatient Drug/Alcohol Rehabilitation No copayment 90% of billed charges; after applicable coinsurance max, covered in full (see pages 18–19 for details)

Durable Medical Equipment No copayment (HCAP) 50% of network allowance (see the Empire Plan Certificate)

Prosthetics No copayment14 Basic Medical3,14 $1,500 lifetime maximum benefit for prosthetic wigs not subject to deductible or coinsurance

Orthotic Devices No copayment14 Basic Medical3,14

Rehabilitative Care (not covered in a skilled nursing facility if Medicare primary)

No copayment as an inpatient; $25 per visit for outpatient physical therapy following related surgery or hospitalization15

Physical or occupational therapy $25 per visit (MPN)

Speech therapy $25 per visit

$250 annual deductible, 50% of network allowance

Basic Medical3

Diabetic Supplies No copayment (HCAP) 50% of network allowance (see the Empire Plan Certificate)

Insulin and Oral Agents(covered under the Prescription Drug Program, subject to drug copayment)

Diabetic Shoes $500 annual maximum benefit 75% of network allowance up to an annual maximum benefit of $500 (see the Empire Plan Certificate)

Hospice No copayment, no limit 10% of billed charges up to the combined annual coinsurance maximum

Skilled Nursing Facility16,17 No copayment 10% of billed charges up to the combined annual coinsurance maximum



Prescription Drugs (see pages 20–21) Specialty Drugs (see page 21)Additional Benefits: Dental (preventive) Not covered Not covered Vision (routine only) Not covered Not covered Hearing Aids No network benefit.

See nonparticipating provider.Up to $1,500 per aid per ear every 4 years (every 2 years for children) if medically necessary

Annual Out-of-Pocket Maximum Individual coverage: $2,850 for the Prescription Drug Program.17$5,300 shared maximum for the Hospital, Medical/Surgical and Mental Health/Substance Abuse Programs.Family coverage: $5,700 for the Prescription Drug Program.17 $10,600 shared maximum for the Hospital, Medical/Surgical and Mental Health/Substance Abuse Programs.

Not available

Out-of-Area Benefit Benefits for covered services are available worldwide.

24-hour NurseLineSM for health information and support at 1-877-7-NYSHIP (1-877-769-7447); press or say Option 5.

Voluntary disease management programs available for conditions such as asthma, attention deficit hyperactivity disorder (ADHD), cardiovascular disease, chronic kidney disease (CKD), chronic obstructive pulmonary disease, congestive heart failure, depression, diabetes and eating disorders.

Diabetes education centers for enrollees who have a diagnosis of diabetes.

For more information regarding covered vaccines, tests and screenings, see the Empire Plan Preventive Care Coverage Chart on NYSHIP Online under Publications or visit www.hhs.gov/healthcare/rights/preventive-care.

1 Inpatient stays at network hospitals are paid in full. Provider charges are covered under the Medical/Surgical Program. Non-network hospital coverage provided subject to coinsurance (see page 16).

2 Copayment waived for preventive services under the PPACA. See www.hhs.gov/healthcare/rights/preventive-care or NYSHIP Online for details. Diagnostic services require plan copayment or coinsurance.

3 See Cost Sharing (beginning on page 18) for Basic Medical information.

14 Benefit paid up to cost of device meeting individual’s functional need. 15 Physical therapy must begin within six months of the related surgery or

hospitalization and be completed within 365 days of the related surgery or hospitalization.

16 Up to 120 benefit days; Benefits Management Program provisions apply. 17 Does not apply to Medicare-primary enrollees.
















Benefits Enrollee CostOffice Visits $25 per visit

($5 for children to age 26)Annual Adult Routine Physicals No copayment

Well Child Care No copaymentSpecialty Office Visits $40 per visitDiagnostic/Therapeutic Services

Radiology $40 per visitLab Tests No copaymentPathology No copaymentEKG/EEG No copaymentRadiation $25 per visitChemotherapy $25 for Rx injection and $25 office copayment (max two copayments per day)

Dialysis No copaymentWomen’s Health Care/Reproductive Health

Pap Tests No copaymentMammograms No copaymentPrenatal Visits No copaymentPostnatal Visits No copaymentBone Density Tests No copayment (routine) $40 copayment (diagnostic)Breastfeeding Services No copayment and Equipment must be purchased from a participating Durable Medical Equipment provider

External Mastectomy Prosthesis No copaymentFamily Planning Services $25 PCP,

$40 specialist per visitInfertility Services Applicable physician/

facility copaymentContraceptive Drugs Applicable Rx copayment 1

Contraceptive Devices Applicable Rx copayment 1

Inpatient Hospital Surgery Physician No copayment

Facility No copayment

Benefits Enrollee CostOutpatient Surgery

Hospital $50 per visitPhysician’s Office $50 copayment or 20% coinsurance, whichever is less

Outpatient Surgery Facility $40 physician and $50 facility per visit

Emergency Department $100 per visit (waived if admitted within 24 hours)

Urgent Care Facility $35 per visitAmbulance $100 per tripOutpatient Mental Health

Individual $25 per visit ($5 for children to age 26) Group $25 per visit ($5 for children to age 26)Inpatient Mental Health No copayment

unlimitedOutpatient Drug/Alcohol Rehab $25 per visit

($5 for children to age 26)Inpatient Drug/Alcohol Rehab No copayment

unlimitedDurable Medical Equipment 50% coinsuranceProsthetics 50% coinsuranceOrthotics 50% coinsuranceRehabilitative Care, Physical, Speech and Occupational Therapy

Inpatient, 60 days max No copaymentOutpatient Physical or $40 per visit Occupational Therapy, 30 visits max for all outpatient services combined

Outpatient Speech Therapy, $40 per visit 30 visits max for all outpatient services combined

Diabetic Supplies $25 per item up to a 30-day supply

Insulin and Oral Agents $25 per prescription up to a 30-day supply

Diabetic Shoes 50% coinsurance one pair per year when medically necessary

Hospice, 210 days max No copayment

1 Generic oral contraceptives and certain OTC contraceptive devices are covered in full in accordance with the Affordable Care Act.


Benefits Enrollee CostSkilled Nursing Facility No copayment

45 days max per admission, 360-day lifetime maxPrescription Drugs

Retail, 30-day supply $10 Tier 1, $30 Tier 2, $50 Tier 3 2

Mail Order, up to 90-day supply $20 Tier 1, $60 Tier 2, $100 Tier 3 2

You can purchase a 90-day supply of a maintenance medication at a retail pharmacy for a $30, $90 or $150 copayment. You are limited to a 30-day supply for the first fill. Coverage includes fertility drugs, injectable and self-injectable medications and enteral formulas.

Specialty DrugsDesignated specialty drugs are covered only at a network specialty pharmacy, subject to the same days’ supply and cost-sharing requirements as the retail benefit, and cannot be filled via mail order. A current list of specialty medications and pharmacies is available at www.excellusbcbs.com.

Additional BenefitsAnnual Out-of-Pocket Maximum (In-Network Benefits) ................................$6,350 Individual, $12,700 Family per yearDental3 ......................................................................................$40 per visitVision4 ........................................................................................$40 per visitHearing Aids ......................................................Children to age 19:

Covered in full for up to two hearing aids every three years

Out of Area ...................................................................... Our BlueCardand Away From Home Care Programs cover routine and urgent care while traveling, for students away at school, members on extended out-of-town business and for families living apart

Maternity Physician’s charge for delivery ............$50 copaymentTelemedicine .......................................................................$10 per visit

We have partnered with MDLIVE® to provide you with a faster way to access healthcare for non-emergency medical conditions and behavioral health conditions through telemedicine.

Plan Highlights for 2020Laboratory and pathology services are covered in full. We deliver high-quality coverage, plus discounts on

services that encourage you to keep a healthy lifestyle. Excellus BCBS, via our partner MDLIVE®, now offers another low-cost way to receive care. Visit with a U.S. board-certified doctor right from your home, office or on the go for non-emergency medical and behavioral health conditions for only a $10 copayment.

Participating PhysiciansWith more than 3,200 providers available, Blue Choice offers you more choice of doctors than any other area HMO.

Affiliated HospitalsAll hospitals in the Blue Choice service area are available to you, plus some outside the service area. Please call for a directory, or visit www.excellusbcbs.com.

Pharmacies and PrescriptionsFill prescriptions at any of our more than 60,000 participating pharmacies nationwide. Blue Choice offers convenient mail-order services for select maintenance drugs. Blue Choice offers an incented formulary.

Medicare CoverageMedicare-primary NYSHIP enrollees must enroll in Medicare Blue Choice, our Medicare Advantage Plan. To qualify, you must be enrolled in Medicare Parts A and B and live in the service area. Some copayments will vary.

Important Note: Only participating providers in the counties listed below are part of this HMO’s network within NYSHIP. Please be sure to check before receiving care that your provider participates with this HMO’s NYSHIP network.

NYSHIP Code Number 066A Network HMO serving individuals living or working in the following select counties: Livingston, Monroe, Ontario, Seneca, Wayne and Yates.

Blue Choice165 Court Street, Rochester, NY 14647

For information:Blue Choice: 1-800-499-1275TTY: 1-800-662-1220Medicare Blue Choice: 1-877-883-9577Website: www.excellusbcbs.com

2 If your doctor prescribes a brand-name drug when an FDA-approved generic equivalent is available, you pay the difference between the cost of the generic and the brand-name drug, plus any applicable copayments.

3 Coverage for accidental injury to sound and natural teeth and for care due to congenital disease or anomaly; routine care not covered.

4 Coverage for exams to treat a disease or injury; routine care not covered.


http://www.excellusbcbs.com



Benefits Enrollee CostOffice Visits $10 per visit 1

Annual Adult Routine Physicals No copayment Well Child Care No copaymentSpecialty Office Visits $18 per visitDiagnostic/Therapeutic Services

Radiology $18 per visitLab Tests No copayment 2

Pathology No copaymentEKG/EEG $18 per visitRadiation $18 per visitChemotherapy $18 per visit


Pap Tests No copaymentMammograms No copaymentPrenatal Visits $10 for initial visit only 3

Postnatal Visits $18 per visitBone Density Tests No copaymentBreastfeeding Services No copayment 4 and Equipment

External Mastectomy Prosthesis No copayment one per breast per year

Family Planning Services $18 per visitInfertility Services5 $18 per visitContraceptive Drugs No copayment 6

Contraceptive Devices No copayment 6

Inpatient Hospital Surgery No copayment


Hospital $100 per visitPhysician’s Office $18 per visit

Outpatient Surgery Facility $100 per visitEmergency Department $100 per visit

(waived if admitted)Urgent Care Facility7 $25 per visitAmbulance $100 per tripOutpatient Mental Health

Individual, unlimited $10 per visit Group, unlimited $10 per visitInpatient Mental Health No copayment


unlimitedInpatient Drug/Alcohol Rehab No copayment


Inpatient, 45 days max No copaymentOutpatient Physical or $18 per visit Occupational Therapy, 20 visits max8

Outpatient Speech Therapy, $18 per visit 20 visits max8

1 $0 copayment for primary care visits for children age 19 and under.2 For services at a standalone Quest lab or outpatient hospital that participates as a Quest Diagnostics hospital draw site. Lab

services performed in conjunction with outpatient surgery or an emergency department visit are also paid in full.3 One-time $10 copayment to confirm pregnancy. No copayment for inpatient maternity care or gestational diabetes screenings.4 $170 allowance towards the purchase of one manual or electric breast pump at a participating provider per pregnancy; you pay the

difference for an upgraded model. Rental only for a hospital grade pump, covered for the duration of breastfeeding. 5 For services to diagnose and treat infertility. See “Additional Benefits” for artificial insemination.6 No copayment for contraceptive drugs and devices unless a generic equivalent is available, in which case you are subject to

a $30 (Tier 2) or $60 (Tier 3) copayment. A mail-order supply costs 2.5 times the applicable copayment.7 Urgent Care is covered outside of our eight-county service area of Western New York.8 Twenty visits in aggregate for physical therapy, occupational therapy and speech therapy.


Benefits Enrollee CostDiabetic Supplies $10 per itemInsulin and Oral Agents $10 per itemDiabetic Shoes Not coveredHospice No copayment 210 days max per yearSkilled Nursing Facility No copayment

50 days max per plan yearPrescription Drugs

Retail, 30-day supply $5 Tier 1, $30 Tier 2, $60 Tier 3 Mail Order, 90-day supply $12.50 Tier 1, $75 Tier 2, $150 Tier 3

May require prior approval. Over 600 $0 preventive drugs available.

Specialty DrugsAvailable through mail order at the applicable copayment.

Additional BenefitsAnnual Out-of-Pocket Maximum (In-Network Benefits) ................................$3,000 Individual, $6,000 Family per yearDental.........................................................................................Not coveredVision .......................................................................Discounts available 9

Hearing Aids10.........................................Plan covers up to twoTruHearing Flyte hearing aids every year (one per ear per year).

Out of Area ...................................................Worldwide coveragefor emergency care through the BlueCard Program. Away From Home Care (AFHC) allows you to obtain coverage through a nearby Blue HMO when you are away from home and our service area.

Artificial Insemination & In Vitro Fertilization .................................20% coinsuranceThree treatment rounds of IVF per lifetime max, other artificial means to induce pregnancy (embryo transfer, etc.) are not covered.

Wellness Services ................................. $500 Wellness Card allowance for use at participating facilities

Plan Highlights for 2020Wellness allowance may be used for, but not limited to, acupuncture, massage therapy, chiropractic visits and health food stores. Visit www.bcbswny.com for information on discounts and wellness programs. You can use Telemedicine hosted by Doctor on Demand at no copayment. Over 600 $0 preventive drugs available and no copayment for pediatric PCP visits, age 19 and under.

Participating PhysiciansYou have access to 7,000+ physicians/healthcare professionals.

Affiliated HospitalsYou may receive care at all Western New York hospitals and other hospitals if medically necessary.

Pharmacies and PrescriptionsOur network includes 45,000 participating pharmacies. Prescriptions filled up to 30-day supply. BlueCross BlueShield offers an incented formulary.

Medicare CoverageMedicare-primary enrollees are required to enroll in Senior Blue HMO, our Medicare Advantage Plan. To qualify, you must enroll in Medicare Parts A & B and live in the service area.


NYSHIP Code number 067An IPA HMO serving individuals living or working in the following select counties: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming.

BlueCross BlueShield of Western New YorkP.O. Box 80, Buffalo, NY 14240-0080

For information:BlueCross BlueShield of Western New York: 716-887-8840 or 1-877-576-6440TTY: 711Website: www.bcbswny.com/NYSHIP

9 Call 1-888-497-7419 for discount information.10 If you do not use TruHearing, your benefit is subject to 50% coinsurance. TruHearing may be reached at 1-800-334-1807.


http://www.bcbswny.com

http://www.bcbswny.com/NYSHIP



Radiology $20 per visit 1

Lab Tests $20 per visit 2

Pathology $20 per visit 2

EKG/EEG $20 per visit 1

Radiation $20 per visitChemotherapy $20 per visit

Dialysis $20 per visitWomen’s Health Care/Reproductive Health

Pap Tests No copaymentMammograms No copaymentPrenatal Visits $20 initial copayment to confirm pregnancy; no copayment for subsequent visitsPostnatal Visits No copaymentBone Density Tests No copaymentBreastfeeding Services No copayment and Equipment

External Mastectomy Prosthesis 20% coinsuranceFamily Planning Services No copaymentInfertility Services $20 per visitContraceptive Drugs No copayment 3

Contraceptive Devices No copayment 3

Inpatient Hospital Surgery No copaymentOutpatient Surgery


Outpatient Surgery Facility $75 per visit

Benefits Enrollee CostEmergency Department $50 per visit

(waived if admitted within 24 hours)Urgent Care Facility $25 per visitAmbulance $50 per tripOutpatient Mental Health



unlimitedInpatient Drug/Alcohol Rehab No copayment

unlimitedDurable Medical Equipment 20% coinsuranceProsthetics 20% coinsuranceOrthotics4 20% coinsuranceRehabilitative Care, Physical, Speech and Occupational Therapy

Inpatient, 60 days max No copaymentOutpatient Physical or $20 per visit Occupational Therapy, 30 visits max each per calendar year

Outpatient Speech Therapy, $20 per visit 20 visits max per calendar year

Diabetic SuppliesRetail, 30-day supply $20 per item

Mail Order, 90-day supply $50 per itemInsulin and Oral Agents

Retail, 30-day supply $20 per item Mail Order, 90-day supply $50 per itemDiabetic Shoes $20 per pair

one pair per year when medically necessaryHospice No copayment

210 days max

1 Waived if provider is a preferred center.2 Waived if provider is a designated laboratory.3 OTC contraceptives with a written physician order/prescription will be reimbursed at no member cost share. OTC

contraceptives without a prescription will not be covered. Non-formulary contraceptives require prior authorization to be covered at no copayment. If not approved, 100% member liability applies.

4 Excludes shoe inserts.



45 days maxPrescription Drugs

Retail, 30-day supply $5 Tier 1, $30 Tier 2, $50 Tier 3Mail Order, 90-day supply $12.50 Tier 1, $75 Tier 2, $125 Tier 3Coverage includes injectable and self-injectable medications, fertility drugs and enteral formulas. OTC formulary drugs are subject to Tier 1 copayment. By law, generics match brand-name strength, purity and stability. Ask your doctor about generic alternatives.

Specialty DrugsCertain specialty drugs, regardless of tier, require prior approval, are subject to clinical management programs and must be filled by a network specialty pharmacy. Contact Caremark Specialty Pharmacy Services at 1-800-237-2767. A representative will work with your doctor and arrange delivery.

Additional BenefitsAnnual Out-of-Pocket Maximum (In-Network Benefits) ................................$6,850 Individual, $13,700 Family per yearDental.........................................................................................Not coveredVision ..........................................................................................Not coveredLaser Vision Correction .................$750 reimbursement

Once per lifetime benefitHearing Aids .........................................................20% coinsurance 5

Out of Area ......................... Coverage for emergency careout of area. College students are also covered for preapproved follow-up care.

Allergy Injections ....................................................No copaymentDiabetes Self-Management Education ......$20 per visitGlucometer ..................................................................$20 per deviceAcupuncture ...................................................................... $20 per visit

10 visits maxDiabetic Prevention Program .........Copayment varies

depending on program, unlimitedVirtual Doctor Visits ................................................. $20 per visitWeight Loss Program

Reimbursement .....................Members who participatein a weight loss program with a preferred vendor are eligible for a once per benefit period reimbursement of up to $75 for a completed program.

Fitness Reimbursement .................................$200 enrollee/$100 spouse per 50 gym visits; available twice per plan year

Plan Highlights for 2020With Rx for Less, get deep discounts on specified generic prescriptions filled at any CVS, Walmart, Hannaford, ShopRite or Price Chopper/Market 32.

Participating PhysiciansCDPHP has nearly 10,000 participating practitioners and providers.

Affiliated HospitalsCDPHP is affiliated with most major hospitals in our service area. An out-of-network facility or Center of Excellence can be approved for special care needs.

Pharmacies and PrescriptionsCDPHP offers a closed formulary with few excluded drugs. Log in to Rx Corner at www.cdphp.com to find participating pharmacies and view claims. Mail order saves money; find forms online or call 518-641-3700 or 1-800-777-2273.

Medicare CoverageMedicare-primary NYSHIP retirees and dependents must enroll in CDPHP Group Medicare Rx (HMO). To qualify, you must have Medicare Parts A and B and live in the service area.


NYSHIP Code number 063An IPA HMO serving individuals living or working in the following select counties: Albany, Columbia, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington.

NYSHIP Code number 300An IPA HMO serving individuals living or working in the following select counties: Broome, Chenango, Essex, Hamilton, Herkimer, Madison, Oneida, Otsego and Tioga.

NYSHIP Code number 310An IPA HMO serving individuals living or working in the following select counties: Delaware, Dutchess, Orange and Ulster.

Capital District Physicians’ Health Plan, Inc. (CDPHP)500 Patroon Creek Boulevard, Albany, NY 12206-1057

For information:Member Services: 518-641-3700 or 1-800-777-2273TTY: 711Website: www.cdphp.com

5 One per ear, every three years.


http://www.cdphp.com

http://www.cdphp.com



Radiology No copaymentLab Tests No copaymentPathology No copaymentEKG/EEG No copaymentRadiation No copaymentChemotherapy $10 per visit for specialist, no copayment for hospital and PCP


Pap Tests No copaymentMammograms No copaymentPrenatal Visits No copaymentPostnatal Visits No copaymentBone Density Tests No copaymentBreastfeeding Services No copayment and Equipment


$10 specialist per visitInfertility Services $10 per visitContraceptive Drugs1 No copaymentContraceptive Devices1 No copaymentInpatient Hospital Surgery No copaymentOutpatient Surgery

Hospital No copaymentPhysician’s Office $5 PCP, $10 specialist per visit

Outpatient Surgery Facility No copaymentEmergency Department $75 per visit

(waived if admitted)

Benefits Enrollee CostUrgent Care Facility $5 copaymentAmbulance No copaymentOutpatient Mental Health No copayment

unlimitedInpatient Mental Health No copayment

unlimitedOutpatient Drug/Alcohol Rehab $5 PCP,

unlimited $10 specialist per visitInpatient Drug/Alcohol Rehab No copayment

unlimitedDurable Medical Equipment No copaymentProsthetics No copaymentOrthotics No copaymentRehabilitative Care, Physical, Speech and Occupational Therapy

Inpatient, 30 days max No copaymentOutpatient Physical or $10 per visit Occupational Therapy, 90 visits max for all outpatient rehabilitative care

Outpatient Speech Therapy, $10 per visit 90 visits max for all outpatient rehabilitative care

Diabetic Supplies $5 per 34-day supplyInsulin and Oral Agents $5 per 34-day supplyDiabetic Shoes2 No copayment

when medically necessaryHospice No copayment

210 days maxSkilled Nursing Facility No copayment

unlimitedPrescription Drugs

Retail, 30-day supply $5 Tier 1, $20 Tier 2Mail Order, 90-day supply $7.50 Tier 1, $30 Tier 2Subject to drug formulary, includes fertility drugs, injectable and self-injectable medications and enteral formulas. Copayments reduced by 50 percent when utilizing EmblemHealth mail-order service. Up to a 90-day supply of generic or brand-name drugs may be obtained.

1 Covered for FDA-approved contraceptive drugs and devices only.2 Precertification must be obtained from the participating vendor prior to purchase.

an EmblemHealth Company


Specialty DrugsCoverage provided through the EmblemHealth Specialty Pharmacy Program. Specialty drugs include injectables and oral agents that are more complex to administer, monitor and store in comparison with traditional drugs. Specialty drugs require prior approval, which can be obtained by the HIP prescribing physician. Specialty drugs are subject to the applicable Rx copayment, Rx formulary and distribution from our preferred specialty pharmacy.

Additional BenefitsAnnual Out-of-Pocket Maximum (In-Network Benefits) ................................$6,850 Individual, $13,700 Family per yearDental.........................................................................................Not coveredVision ..................................................... No copayment for routine and refractive eye examsEyeglasses ..............................................................................$35 per pair

one pair every 24 months for selected framesLaser Vision Correction (LASIK) ......Discount programHearing Aids ......................................... Cochlear implants onlyOut of Area ............... Covered for emergency care onlyFitness Program ..............................................Discount programAlternative Medicine Program........Discount programArtificial Insemination...............................................$10 per visitProstate Cancer Screening .........................No copayment

Plan Highlights for 2020The HIP Prime network has more than 69,000 physicians practicing at 219,000 locations. HIP, an EmblemHealth company, has been providing health benefits to hardworking New Yorkers for nearly seven decades and is committed to building a healthy future for you and your family. More information is available at www.emblemhealth.com.

Participating PhysiciansThe HIP Prime network offers the choice of a traditional network of independent physicians who see patients in their own offices, as well as providers in physician group practices that meet most, if not all, of a member’s medical needs under one roof. Group practices offer services in most major specialties such as cardiology and ophthalmology, plus ancillary services like lab tests, X-rays and pharmacy services.

Affiliated HospitalsHIP Prime members have access to more than 100 of the area’s leading hospitals, including major teaching institutions.

Pharmacies and PrescriptionsFilling a prescription is easy with more than 40,000 participating pharmacies nationwide, including more than 4,700 participating pharmacies throughout New York State. HIP Prime members have access to a mail-order program through Express Scripts. The HIP Prime Plan offers a closed formulary. Tier 1 includes generic drugs; Tier 2 includes brand-name drugs.

Medicare CoverageRetirees who are not Medicare-eligible are offered the same coverage as active employees. Medicare-primary retirees who reside in NYSHIP-approved downstate service counties are required to enroll in the VIP Premier (HMO) Medicare Plan, a Medicare Advantage Plan that provides Medicare benefits and more. To qualify, you must be enrolled in Medicare Parts A and B and live in the service area.


NYSHIP Code number 050A Network and IPA HMO serving individuals living or working in the following select counties: Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk and Westchester.

NYSHIP Code number 220An IPA HMO serving individuals living or working in the following select counties: Albany, Columbia, Greene, Rensselaer, Saratoga, Schenectady, Warren and Washington.

NYSHIP Code number 350An IPA HMO serving individuals living or working in the following select counties: Delaware, Dutchess, Orange, Putnam, Sullivan and Ulster.

EmblemHealth55 Water Street, New York, NY 10041

For information:Customer Service: 1-800-447-8255TTY: 1-888-447-4833Website: www.emblemhealth.com


http://www.emblemhealth.com

http://www.emblemhealth.com



Radiology $40 per visitLab Tests No copaymentPathology No copaymentEKG/EEG No copaymentRadiation $25 per visitChemotherapy $25 per visit


Pap Tests No copaymentMammograms No copaymentPrenatal Visits1 No copayment Postnatal Visits No copaymentBone Density Tests No copayment

Breastfeeding Services No copayment and EquipmentMust be purchased from a participating Durable Medical Equipment provider


$40 specialist per visitInfertility Services Applicable physician/

facility copaymentContraceptive Drugs Applicable Rx copayment 2

Contraceptive Devices Applicable Rx copayment 2

Inpatient Hospital SurgeryPhysician $200 copayment or 20% coinsurance, whichever is less

Facility No copayment


Hospital $40 physician copayment per visitPhysician’s Office $50 copayment or 20% coinsurance, whichever is less

Outpatient Surgery Facility $50 per visitEmergency Department $100 per visit

(waived if admitted)Urgent Care Facility $35 per visitAmbulance $100 per tripOutpatient Mental Health

Individual, unlimited $25 per visit ($5 for children to age 26)

Group, unlimited $25 per visit ($5 for children to age 26)

Inpatient Mental Health No copayment unlimited

Outpatient Drug/Alcohol Rehab $25 per visit unlimited ($5 for children to age 26)

Inpatient Drug/Alcohol Rehab No copayment unlimited

Durable Medical Equipment 50% coinsuranceProsthetics 50% coinsuranceOrthotics 50% coinsuranceRehabilitative Care, Physical, Speech and Occupational Therapy

Inpatient, 60 days max No copaymentOutpatient Physical or $40 per visit Occupational Therapy, 30 visits max for all outpatient services combined

Outpatient Speech Therapy, $40 per visit 30 visits max for all outpatient services combined

Diabetic Supplies $25 per item 30-day supply

Insulin and Oral Agents $25 per item 30-day supply

Diabetic Shoes 50% coinsurance three pairs per year when medically necessary

1 $200 physician charge for delivery or 20% coinsurance, whichever is less.2 Generic oral contraceptives and certain OTC contraceptive devices covered in full in accordance with the Affordable Care Act.


Benefits Enrollee CostHospice No copayment

210 days maxSkilled Nursing Facility No copayment

45 days max per calendar yearPrescription Drugs

Retail, 30-day supply $10 Tier 1, $30 Tier 2, $50 Tier 3 3

Mail Order, 90-day supply $20 Tier 1, $60 Tier 2, $100 Tier 3 3

Coverage includes injectable and self-injectable medications, fertility drugs and enteral formulas.

Specialty DrugsSpecialty medications after the initial first fill must be purchased from one of our participating specialty pharmacies. A current list of specialty medications and pharmacies is available on our website.

Additional BenefitsAnnual Out-of-Pocket Maximum (In-Network Benefits) ................................$6,350 Individual, $12,700 Family per yearDental.........................................................................................Not coveredVision .................................................$40 per visit for eye exams associated with disease or injuryHearing Exam ...................................................................$40 per visit for routine (once every 12 months) and diagnosticHearing Aids ......................................................Children to age 19:

Covered in full for up to two hearing aids every three years; $40 copayment per visit for fittings

Out of Area ..........................................................The BlueCard andAway From Home Care Programs provide routine and urgent care coverage while traveling, for students away at college, members on extended out-of-town business and families living apart

Smoking Cessation ............The Quit For Life program isan award-winning support program to help you quit using tobacco for good. Call 1-800-442-8904 or go to www.quitnow.net/Excellus for more information.

Telemedicine .......................................................................$10 per visitWe have partnered with MDLIVE® to provide you with a faster way to access healthcare for non-emergency medical conditions and behavioral health conditions through telemedicine.

Plan Highlights for 2020We deliver high-quality coverage, plus discounts on services that encourage you to keep a healthy lifestyle.

Participating PhysiciansHMOBlue is affiliated with more than 4,700 physicians and health care professionals.

Affiliated HospitalsAll hospitals within our designated service area participate with HMOBlue. Members may be directed to other hospitals to meet special needs when medically necessary.

Pharmacies and PrescriptionsHMOBlue members may purchase prescription drugs from more than 60,000 participating FLRx network pharmacies nationwide. We offer an incented formulary.

Medicare CoverageMedicare-primary NYSHIP enrollees must enroll in Medicare Blue Choice HMO, our Medicare Advantage Plan. To qualify, you must be enrolled in Medicare Parts A and B and live in the service area. Some copayments will vary.


NYSHIP Code number 072An IPA HMO serving individuals living or working in the following select counties: Broome, Cayuga, Chemung, Cortland, Onondaga, Oswego, Schuyler, Steuben, Tioga and Tompkins.

NYSHIP Code number 160An IPA HMO serving individuals living or working in the following select counties: Chenango, Clinton, Delaware, Essex, Franklin, Fulton, Hamilton, Herkimer, Jefferson, Lewis, Madison, Montgomery, Oneida, Otsego and St. Lawrence.

Excellus BlueCross BlueShieldHMOBlue 072 333 Butternut Drive Syracuse, NY 13214-1803

Excellus BlueCross BlueShieldHMOBlue 160 12 Rhoads Drive, Utica, NY 13502

For information:HMOBlue Customer Service: 1-800-499-1275TTY: 1-800-662-1220Website: www.excellusbcbs.com

3 If a doctor selects a brand-name drug (Tier 2 or Tier 3) when an FDA-approved generic equivalent is available, the benefit will be based on the generic drug’s cost, and the member will have to pay the difference, plus any applicable copayments. If your prescription has no approved generic available, your benefit will not be affected.


http://www.quitnow.net/Excellus


Benefits Enrollee CostOffice Visits

Adult (19+) $20 Child (0-18) $0 per visitAnnual Adult Routine Physicals No copayment

Well Child Care No copaymentSpecialty Office Visits $20 per visitDiagnostic/Therapeutic Services

Radiology $20 per visit 1

Lab Tests $10 per visit 2

Pathology $10 per visitEKG/EEG $20 per visit 1

Radiation $20 per visit 1

Chemotherapy $20 per visit 1


Pap Tests No copaymentMammograms No copaymentPrenatal Visits No copaymentPostnatal Visits No copaymentBone Density Tests No copaymentBreastfeeding Services No copayment and Equipment

External Mastectomy Prosthesis No copayment unlimited

Family Planning Services3 $20 per visitInfertility Services

Office $20 per visit Outpatient Surgery Facility $100 per visitContraceptive Drugs No copaymentContraceptive Devices No copaymentInpatient Hospital Surgery No copaymentOutpatient Surgery




(waived if admitted within 24 hours)Urgent Care Facility Adult (19+) $35 per visit

Child (0-18) $0 per visitAmbulance $100 per tripOutpatient Mental Health Adult (19+), unlimited $20 per visit Child (0-18), unlimited $0 per visitInpatient Mental Health No copayment

unlimitedOutpatient Drug/Alcohol Rehab Adult (19+), unlimited $20 per visit Child (0-18), unlimited $0 per visitInpatient Drug/Alcohol Rehab No copayment

unlimitedDurable Medical Equipment 50% coinsuranceProsthetics No copaymentOrthotics No copaymentRehabilitative Care, Physical, Speech and Occupational Therapy

Inpatient, 45 days max No copaymentOutpatient Physical or $20 per visit Occupational Therapy, 20 visits max per year for all outpatient services combined

Outpatient Speech Therapy, $20 per visit 20 visits max per year for all outpatient services combined

Diabetic SuppliesRetail, 90-day supply $20 per item

Mail Order Not availableInsulin and Oral Agents

Retail $20 or applicable Rx copayment, whichever is less

Mail Order $45 or applicable Rx copayment, whichever is less

1 Office based: $20 copayment; hospital based: $40 copayment. $0 copayment for child (0-18) in a PCP office.2 No copayment for lab tests drawn and processed in a primary care or specialist setting.3 Only preventive family planning services are covered in full. Non-preventive services require a copayment.


Benefits Enrollee CostDiabetic Shoes No copayment

one pair per year when medically necessaryHospice No copayment unlimitedSkilled Nursing Facility No copayment

45 days maxPrescription Drugs

Retail, 30-day supply Adult (19+) $5 Tier 1, $30 Tier 2, $60 Tier 3 Child (0-18) $0 Tier 1, $30 Tier 2, $60 Tier 3Mail Order, 90-day supply Adult (19+) $12.50 Tier 1, $75 Tier 2, $150 Tier 3 Child (0-18) $0 Tier 1, $75 Tier 2, $150 Tier 3Coverage includes injectable and self-injectable medications, fertility drugs and enteral formulas.

Specialty DrugsBenefits are provided for specialty drugs by two contracted specialty pharmacy vendors, Reliance Rx Pharmacy and Walgreens Specialty Pharmacy. Specialty drugs, available through the prescription drug benefit, include select high-cost injectables and oral agents such as oral oncology drugs. Specialty drugs require prior approval and are subject to the applicable Rx copayment based on the formulary status of the medication.

Additional BenefitsAnnual Out-of-Pocket Maximum (In-Network Benefits) ................................$4,000 Individual,` $8,000 Family per yearDental................................................Discount program availableVision .............................$10 per visit once every 12 months (routine only)Eyeglasses ...................................$50 for single vision lenses, frames; 40% off retail priceHearing Aids .........Discounts available at different tiers from select providers. Contact plan for details.Out of Area .............................................While traveling outside

of the service area, members are covered for emergency and urgent care center situations only. In addition, dependents up to age 26 are covered when seeing a provider in our national network if they reside outside the service area for more than 90 days but less than 365 days. Please see our website for details.

Home Health Care ..................................................... $20 per visit40 visits max

Wellness Services ..............................................$400 allowance for use at a participating facilityUrgent Care in Service Area

for After-Hours Care ............................................$35 per visit 4

Plan Highlights for 2020$0 copayment for children aged 18 and under for primary care and Tier 1 prescriptions. Wellness card allowance increased to $400 per plan year.

Participating PhysiciansIndependent Health is affiliated with more than 4,000 physicians and health care providers throughout the eight counties of Western New York.

Affiliated HospitalsIndependent Health members are covered at all Western New York hospitals and may be directed to other hospitals when medically necessary.

Pharmacies and PrescriptionsAll retail pharmacies in Western New York participate. Members may obtain prescriptions out of the service area by using our National Pharmacy Network, which includes 58,000 pharmacies nationwide. Independent Health offers a closed formulary.

Medicare CoverageMedicare-primary NYSHIP retirees must enroll in Medicare Encompass, a Medicare Advantage Plan. Copayments differ from the copayments of a NYSHIP-primary enrollee. Call our Member Services Department for detailed information.


NYSHIP Code number 059An IPA HMO serving individuals living or working in the following select counties: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming.

Independent Health511 Farber Lakes Drive, Buffalo, NY 14221

For information:Customer Service: 1-800-501-3439TTY: 716-631-3108Website: www.independenthealth.com

4 $35 copayment for brick-and-mortar freestanding urgent care centers (WNY Immediate Care, WellNow, etc.). $20 copayment for urgent care provided in a participating primary care physician’s office.


http://www.independenthealth.com

Benefits Enrollee CostOffice Visits $25 per visit ($10 for children) 1


Radiology $25 per visitLab Tests No copaymentPathology No copaymentEKG/EEG $25 per visitRadiation $25 per visitChemotherapy $25 per visit


Pap Tests No copaymentMammograms No copaymentPrenatal Visits No copaymentPostnatal Visits No copaymentBone Density Tests No copaymentBreastfeeding Services2 No copayment and Equipment

External Mastectomy Prosthesis3 50% coinsuranceFamily Planning Services4 $25 per visitInfertility Services4 $25 per visitContraceptive Drugs5 No copayment 6

Contraceptive Devices5 No copayment 6

Inpatient Hospital Surgery No copaymentOutpatient Surgery




(waived if admitted)Urgent Care Facility $25 per visitAmbulance $50 per tripOutpatient Mental Health


unlimitedOutpatient Drug/Alcohol Rehab7 $25 per visit

unlimitedInpatient Drug/Alcohol Rehab7 No copayment


Inpatient, 2 months max No copayment per conditionOutpatient Physical or $25 per visit Occupational Therapy, 30 visits max combined

Outpatient Speech Therapy, $25 per visit 30 visits max combined

Diabetic Supplies8 $25 per boxed item 31-day supply

Insulin and Oral Agents8 $25 per boxed item 31-day supply

Diabetic Shoes 50% coinsurance unlimited pairs when medically necessary

Hospice, 210 days max No copayment1 PCP sick visits for children (newborn up to age 26): $10 per visit.2 Please refer to the Certificate of Coverage for requirements/provider specifications regarding Breastfeeding Services and Equipment.3 Please contact MVP for additional information regarding prior authorizations, quantity limits, participating providers, etc.4 Please refer to the Certificate Of Coverage for requirements regarding Infertility Services.5 Over-the-counter contraceptives are not covered.6 Brand-name contraceptives with generic equivalents require member payment of the difference in cost between the generic

and brand-name drugs, plus the Tier 1 copayment.7 Please refer to the Certificate of Coverage for requirements regarding Substance Use Disorder.8 Please refer to the Certificate of Coverage for requirements regarding Diabetic Supplies.



45 days max per calendar yearPrescription Drugs

Retail, 30-day supply $10 Tier 1, $30 Tier 2, $50 Tier 3Mail Order, up to 90-day supply $25 Tier 1, $75 Tier 2, $125 Tier 3If a member requests a brand-name drug over the prescribed generic, they pay the difference between the cost of the generic and the brand-name drug plus the Tier 1 copayment. This includes fertility, injectable and self-injectable medications and enteral formulas. Approved generic contraceptive prescriptions, devices, and those without a generic equivalent are covered at 100% under retail and mail order.

Specialty DrugsRetail covered as noted in Tier 1, Tier 2 and Tier 3 classes. 30-day supply limit. Prior authorization may be required. 30-day supply available through Specialty Pharmacy. Members required to use Caremark Specialty retail.

Additional Benefits Annual Out-of-Pocket Maximum (In-Network Benefits) ................................$6,350 Individual, $12,700 Family per yearDental...................................... $25 preventive visit (to age 19)Vision ......$25 per exam every 24 months (routine only)Hearing Aids ......................................................................Not coveredOut of Area ...........................................................Emergencies only

Plan Highlights for 2020$600 in WellBeing Rewards. Telemedicine provides access to health care professionals including MDs, behavioral health specialists, psychiatrists and more through a mobile device or computer nearly anywhere in the US at a $25 copayment.9

Participating PhysiciansMVP provides services through more than 44,400 physicians and health practitioners throughout its service area.

Affiliated HospitalsMVP members are covered at participating hospitals to which their MVP physician has admitting privileges. Members may be directed to other hospitals to meet special needs when medically necessary upon prior approval from MVP.

Pharmacies and PrescriptionsVirtually all pharmacy “chain” stores and many

independent pharmacies within the MVP service area participate. MVP also offers mail-order service for select maintenance drugs. MVP offers a closed formulary.

Medicare CoverageMedicare-primary NYSHIP enrollees must enroll in the MVP Preferred Gold Plan, MVP’s Medicare Advantage Plan. Some of the MVP Preferred Gold Plan’s copayments may vary from the MVP HMO plan’s copayments. Please contact Member Services for further details.


NYSHIP Code number 058An IPA HMO serving individuals living or working in the following select counties: Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming and Yates.

NYSHIP Code number 060An IPA HMO serving individuals living or working in the following select counties: Albany, Columbia, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington.

NYSHIP Code number 330An IPA HMO serving individuals living or working in the following select counties: Broome, Cayuga, Chenango, Cortland, Delaware, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, Otsego, Tioga and Tompkins.

NYSHIP Code number 340An IPA HMO serving individuals living or working in the following select counties: Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster and Westchester.

NYSHIP Code number 360An IPA HMO serving individuals living or working in the following select counties: Clinton, Essex, Franklin and St. Lawrence.

MVP Health CareP.O. Box 2207, 625 State Street Schenectady, NY 12301-2207

For information:Customer Service: 1-888-MVP-MBRS (687-6277)TTY: 1-800-662-1220Website: www.mvphealthcare.com

9 Please refer to the Certificate of Coverage for requirements regarding Wellbeing Rewards.


http://www.mvphealthcare.com

Reminder: If you are an active employee of New York State and a registered user of MyNYSHIP, you may change your option online (excluding the Opt-out Program) during the Option Transfer Period. See your HBA if you have questions.

It is now necessary to have a personal NY.gov ID to access MyNYSHIP. For more information and instructions, visit www.cs.ny.gov/mynyship/welcome

NYSHIP Online, the New York State Department of Civil Service website, is designed to provide you with targeted information about your NYSHIP benefits. Visit NYSHIP Online at www.cs.ny.gov/employee-benefits and select your group and plan, if prompted.

Ask your HBA for a copy of the NYSHIP Online flyer, which provides helpful navigation information.

NYSHIP Online



http://www.cs.ny.gov/mynyship/welcome

How to Find Answers to Your Benefit Questions and Access Additional Important Information• If you are an active employee, contact your HBA (usually located in your agency’s Personnel Office or the

Business Services Center).• If you have questions regarding health insurance claims for The Empire Plan, call 1-877-7-NYSHIP

(1-877-769-7447) toll free and choose the appropriate program from the main menu. HMO enrollees should contact their HMOs directly.

• A comprehensive list of contact information for HBAs, HMOs, government agencies, Medicare and other important resources is available on NYSHIP Online in the Using Your Benefits section.


NotesNotes


Notes


The New York State Department of Civil Service, which administers NYSHIP, produced this booklet in cooperation with NYSHIP administrators and Joint Labor/Management Committees on Health Benefits.

Care has been taken to ensure the accuracy of the material contained in this booklet. However, the HMO contracts and the Empire Plan Certificate of Insurance with Amendments are the controlling documents for benefits available under NYSHIP.

It is the policy of the New York State Department of Civil Service to provide reasonable accommodation to ensure effective communication of information in benefits publications to individuals with disabilities. These publications are also available on

NYSHIP Online at www.cs.ny.gov/employee-benefits. Visit NYSHIP Online for timely information that meets universal accessibility standards adopted by New York State for NYS agency websites. If you need an auxiliary aid or service to make benefits information available to you,

please contact your Health Benefits Administrator. COBRA and Young Adult Option enrollees, contact the Employee Benefits Division.

Health Insurance Choices was printed using recycled paper and environmentally sensitive inks. Choices 2020/Active AL1652

2020 Health Insurance Choices (Active) – October 2019


Exhibit Number 23

DENTAL BENEFITS

METROPOLITAN TRANSPORTATION AUTHORITY

THE MTA CONSOLIDATED MANAGERIAL PLAN

Effective January 1, 2008

-i-

TO OUR EMPLOYEES: All of us appreciate the protection and security insurance provides. This certificate describes the benefits that are available to you. We urge you to read it carefully. Benefits are provided through a group policy issued to Metropolitan Transportation Authority by Metropolitan Life Insurance Company.

MTA Consolidated Managerial Plan

-ii-

Metropolitan Life Insurance Company 200 Park Avenue, New York, New York 10166

Certifies that, under and subject to the terms and conditions of the Group Policy issued to the Policyholder, coverage is provided for each Employee as defined herein. The date when an Employee is eligible for coverage is set forth in the form with the title Eligibility for Benefits. The date when an Employee’s Personal Benefits become effective is set forth in the form with the title Effective Dates of Personal Benefits. The date when an Employee's Dependent Benefits become effective is set forth in the form with the title Effective Dates of Dependent Benefits. The amounts of coverage are determined by the form with the title Schedule of Benefits.

C. Robert Henrikson President and Chief Operating Officer

Policyholder: Metropolitan Transportation Authority Group Policy No.: 94072-G Florida Residents: The benefits of the policy providing your coverage are governed primarily by the law of a state other than Florida. For Maryland residents: The group insurance policy providing coverage under this certificate was issued in a jurisdiction other than Maryland and may not provide all of the benefits required by Maryland law.

-iii-

If any prior certificate relating to the coverage set forth herein has been given to the Employee, such certificate is void. Form G.23000-Cert.-1

-iv-

For Texas Residents:

IMPORTANT NOTICE

To obtain information or make a complaint:

You may call MetLife’s toll-free telephone number for information or to make a complaint at

1-800-638-5433

You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at

1-800-252-3439

You may write the Texas Department of Insurance P.O. Box 149104 Austin, TX 78714-9104 Fax # 512 - 475-1771

Web: http://www.tdi.state.tx.us

Email: [email protected]

PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should contact MetLife first. If the dispute is not resolved, you may contact the Texas Department of Insurance.

ATTACH THIS NOTICE TO YOUR CERTIFICATE: This notice is for information only and does not become a part or condition of the attached document.

Para Residentes de Texas:

AVISO IMPORTANTE

Para obtener informacion o para someter una queja:

Usted puede llamar al numero de telefono gratis de MetLife para informacion o para someter una queja al

1-800-638-5433

Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al

1-800-252-3439

Puede escribir al Departamento de Seguros de Texas P.O. Box 149104 Austin, TX 78714-9104 Fax # 512 - 475-1771

Web: http://www.tdi.state.tx.us

Email: [email protected]

DISPUTAS SOBRE PRIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con MetLife primero. Si no se resuelve la disputa, puede entonces comunicarse con el departamento (TDI).

UNA ESTE AVISO A SU CERTIFICADO: Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto.

-v-

Arkansas residents please be advised of the following:

IMPORTANT NOTICE

IF YOU HAVE A QUESTION CONCERNING YOUR COVERAGE OR A CLAIM, FIRST CONTACT YOUR GROUP EMPLOYER OR GROUP ACCOUNT ADMINISTRATOR. IF, AFTER DOING SO, YOU STILL HAVE A CONCERN, YOU MAY CALL METLIFE'S TOLL-FREE TELEPHONE NUMBER:

1-800-638-5433 IF YOU ARE STILL CONCERNED AFTER CONTACTING BOTH YOUR GROUP EMPLOYER AND METLIFE, YOU SHOULD FEEL FREE TO CONTACT:

ARKANSAS INSURANCE DEPARTMENT CONSUMER SERVICES DIVISION

1200 WEST THIRD LITTLE ROCK, ARKANSAS 72201-1904

-vi-

California residents please be advised of the following:

IMPORTANT NOTICE

TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT METLIFE AT:

METROPOLITAN LIFE INSURANCE

COMPANY 200 PARK AVENUE

NEW YORK, NY 10166 ATTN: CORPORATE CONSUMER RELATIONS

DEPARTMENT 1-800-638-5433

IF, AFTER CONTACTING METLIFE REGARDING A COMPLAINT, YOU FEEL THAT A SATISFACTORY RESOLUTION HAS NOT BEEN REACHED, YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA INSURANCE DEPARTMENT AT: CALIFORNIA DEPARTMENT OF INSURANCE

300 SOUTH SPRING STREET LOS ANGELES, CA 90013

1-800-927-4357 (within California) 1-213-897-8921 (outside California)

-vii-

Georgia residents please be advised of the following:

IMPORTANT NOTICE

The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence.

-viii-

NOTICE FOR RESIDENTS OF PENNSYLVANIA Dental Expense Benefits for a Dependent child may be continued past the age limit if that child is a full-time student and benefits end due to the child being ordered to active duty (other than active duty for training) for 30 or more consecutive days as a member of the Pennsylvania National Guard or a Reserve Component of the Armed Forces of the United States. Benefits will continue if such Dependent child: • re-enrolls as a full-time student at an accredited school, college

or university that is licensed in the jurisdiction where it is located; • re-enrolls for the first term or semester, beginning 60 or more

days from the child’s release from active duty; • continues to qualify as a Dependent child, except for the age

limit; and • submits the required Proof of the child’s active duty in the

National Guard or a Reserve Component of the United Stated Armed Forces

Subject to the When Benefits Ends section entitled this continuation will continue until the earliest of the date: • the benefits have been continued for a period of time equal to

the duration of the child’s service on active duty; or • the child is no longer a full-time student.

-ix-

Utah residents please be advised of the following:

NOTICE TO POLICYHOLDERS Insurance companies licensed to sell life insurance, health insurance, or annuities in the State of Utah are required by law to be members of an organization called the Utah Life and Health Insurance Guaranty Association ("ULHIGA"). If an insurance company that is licensed to sell insurance in Utah becomes insolvent (bankrupt), and is unable to pay claims to its policyholders, the law requires ULHIGA to pay some of the insurance company's claims. The purpose of this notice is to briefly describe some of the benefits and limitations provided to Utah insureds by ULHIGA.

PEOPLE ENTITLED TO COVERAGE · You must be a Utah resident. · You must have insurance coverage under an individual or

group policy.

POLICIES COVERED · ULHIGA provides coverage for certain life, health and annuity

insurance policies.

EXCLUSIONS AND LIMITATIONS Several kinds of insurance policies are specifically excluded from coverage. There are also a number of limitations to coverage. The following are not covered by ULHIGA: · Coverage through an HMO. · Coverage by insurance companies not licensed in Utah. · Self-funded and self-insured coverage provided by an employer

that is only administered by an insurance company. · Policies protected by another state's Guaranty Association. · Policies where the insurance company does not guarantee the

benefits. · Policies where the policyholder bears the risk under the policy.

-x-

· Re-insurance contracts. · Annuity policies that are not issued to and owned by an

individual, unless the annuity policy is issued to a pension benefit plan that is covered.

· Policies issued to pension benefit plans protected by the

Federal Pension Benefit Guaranty Corporation. · Policies issued to entities that are not members of the ULHIGA,

including health plans, fraternal benefit societies, state pooling plans and mutual assessment companies.

LIMITS ON AMOUNT OF COVERAGE

Caps are placed on the amount ULHIGA will pay. These caps apply even if you are insured by more than one policy issued by the insolvent company. The maximum ULHIGA will pay is the amount of your coverage or $500,000 — whichever is lower. Other caps also apply: · $100,000 in net cash surrender values. · $500,000 in life insurance death benefits (including cash

surrender values). · $500,000 in health insurance benefits. · $200,000 in annuity benefits — if the annuity is issued to and

owned by an individual or the annuity is issued to a pension plan covering government employees.

· $5,000,000 in annuity benefits to the contract holder of

annuities issued to pension plans covered by the law. (Other limitations apply).

· Interest rates on some policies may be adjusted downward.

-xi-

DISCLAIMER PLEASE READ CAREFULLY: · COVERAGE FROM ULHIGA MAY BE UNAVAILABLE UNDER THIS POLICY. OR, IF AVAILABLE, IT MAY BE SUBJECT TO SUBSTANTIAL LIMITATIONS OR EXCLUSIONS. THE DESCRIPTION OF COVERAGES CONTAINED IN THIS DOCUMENT IS AN OVERVIEW. IT IS NOT A COMPLETE DESCRIPTION. YOU CANNOT RELY ON THIS DOCUMENT AS A DESCRIPTION OF COVERAGE. FOR A COMPLETE DESCRIPTION OF COVERAGE, CONSULT THE UTAH CODE, TITLE 31A, CHAPTER 28. · COVERAGE IS CONDITIONED ON CONTINUED RESIDENCY IN THE STATE OF UTAH. · THE PROTECTION THAT MAY BE PROVIDED BY ULHIGA IS NOT A SUBSTITUTE FOR CONSUMERS' CARE IN SELECTING AN INSURANCE COMPANY THAT IS WELL-MANAGED AND FINANCIALLY STABLE. · INSURANCE COMPANIES AND INSURANCE AGENTS ARE REQUIRED BY LAW TO GIVE YOU THIS NOTICE. THE LAW DOES, HOWEVER, PROHIBIT THEM FROM USING THE EXISTENCE OF ULHIGA AS AN INDUCEMENT TO SELL YOU INSURANCE. · THE ADDRESS OF ULHIGA, AND THE INSURANCE DEPARTMENT ARE PROVIDED BELOW.

Utah Life and Health Insurance Guaranty Association 955 E. Pioneer Rd. Draper, Utah 84114

Utah Insurance Department

State Office Building, Room 3110 Salt Lake City, Utah 84114

-xii-

Virginia residents please be advised of the following:

IMPORTANT INFORMATION REGARDING YOUR INSURANCE In the event you need to contact someone about this insurance for any reason please contact your agent. If no agent was involved in the sale of this insurance, or if you have additional questions you may contact the insurance company issuing this insurance at the following address and telephone number:

Metropolitan Life Insurance Company 200 Park Avenue

New York, New York 10166 Attn: Corporate Customer Relations Department

To phone in a claim related question, you may call Claims Customer Service at:

1-800-638-5433 If you have been unable to contact or obtain satisfaction from the company or the agent, you may contact the Virginia State Corporation Commission's Bureau of Insurance at:

The Office of the Managed Care Ombudsman Bureau of Insurance

P.O. Box 1157 Richmond, VA 23209

1-877-310-6560 - toll-free 1-804-371-9032 - locally www.scc.virginia.gov - web address [email protected] - email

Or:

The Virginia Department of Health (The Center for Quality Health Care Services and Consumer Protection)

3600 West Broad St Suite 216

Richmond, VA 23230 1-800-955-1819

-xiii-

Written correspondence is preferable so that a record of your inquiry is maintained. When contacting your agent, company or the Bureau of Insurance, have your policy number available.

IMPORTANT INFORMATION REGARDING YOUR INSURANCE If you have any questions regarding an appeal or grievance concerning the dental services that you have been provided that have not been satisfactorily addressed by this Dental Insurance, you may contact the Virginia Office of the Managed Care Ombudsman for assistance.

You may contact the Virginia Office of the Managed Care Ombudsman either by dialing toll free at (877) 310-6560, or locally at (804) 371-9032, via the internet at Web address www.scc.virginia.gov, email at [email protected], or mail to:

The Office of the Managed Care Ombudsman Bureau of Insurance, P.O. Box 1157

Richmond, VA 23218

-xiv-

Wisconsin residents please be advised of the following: KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS PROBLEMS WITH YOUR INSURANCE? - If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem.

Metropolitan Life Insurance Company Corporate Consumer Relations Department

200 Park Avenue New York, NY 10166

1-800-638-5433 You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which enforces Wisconsin's insurance laws, and file a complaint. You can contact the OFFICE OF THE COMMISSIONER OF INSURANCE by contacting:

Office of the Commissioner of Insurance Complaints Department

P.O. Box 7873 Madison, WI 53707-7873

1-800-236-8517 outside of Madison or 266-0103 in Madison.

-xv-

TABLE OF CONTENTS Section Page

SCHEDULE OF BENEFITS (Also see SCHEDULE SUPPLEMENT)............................................. 1

SCHEDULE SUPPLEMENT.............................................................. 3

DEFINITIONS OF CERTAIN TERMS USED HEREIN....................... 5

ELIGIBILITY FOR BENEFITS............................................................ 9

EFFECTIVE DATES OF PERSONAL BENEFITS ........................... 11

EFFECTIVE DATES OF DEPENDENT BENEFITS......................... 12

DENTAL EXPENSE BENEFITS ...................................................... 12

WHEN BENEFITS END .................................................................. 30

CONDITIONS UNDER WHICH YOUR ACTIVE WORK IS DEEMED TO CONTINUE ............................................... 31

COORDINATION OF BENEFITS .................................................... 33

NOTICES........................................................................................ 40

1

SCHEDULE OF BENEFITS

(Also see SCHEDULE SUPPLEMENT)

The following Benefits are provided subject to the provisions below.

BENEFITS (EMPLOYEE AND DEPENDENT) AMOUNT

DENTAL EXPENSE BENEFITS

In-Network

Out-of-Network

ANNUAL DEDUCTIBLE AMOUNT Type B and Type C Expenses Combined

Individual ................................................. $0 $50

Family..................................................... $0 $150 Type D Expenses

Individual ................................................. $0 $50 COVERED PERCENTAGE

Type A Expenses (Preventative & Diagnostic)....................

100%

100%

Type B Expenses (Minor Restorative) ... 80% 80%

Type C Expenses (Major Restorative) ... 80% 60%

Type D Expenses (Orthodontics) ........... 80% 60%

2

MAXIMUMS For Orthodontic Treatment Aggregate Maximum Benefit (Lifetime) (For All Dental Expense Periods) ............................. $2,300 For Other Covered Dental Expenses Maximum Benefit (For One Dental Expense Period) ............................ $2,500 NOTE(S) Expenses for orthodontia, including any procedures necessary for such treatment, will be considered Covered Dental Expenses only if the Dependent child has not reached age 19. Employees and Spouses are not covered for orthodontic benefits. Covered Dental Expenses for orthodontia are not included in the Maximum Benefit For One Dental Expense Period. If a dental bill is expected to be $200 or more, see DENTAL EXPENSE BENEFITS, section F. PRE-DETERMINATION OF BENEFITS. COORDINATION OF BENEFITS The Dental Expense Benefits are subject to the provisions of the form entitled COORDINATION OF BENEFITS.

WHEN YOU RETIRE Dental Expense Benefits continue under This Plan on or after the day you retire.

Form G.23000-B

3

SCHEDULE SUPPLEMENT

A. Statements Made by You Which Relate to Insurability

Any statement made by you will be deemed a representation and not a warranty.

No such statement made by you which relates to insurability will be used:

1. in contesting the validity of the benefits with respect to which

such statement was made; or

2. to reduce the benefits;

unless the conditions listed in items (a) and (b) below have been met:

a. The statement must be contained in a written application

which has been signed by you.

b. A copy of the application has been furnished to you.

No such statement made by you will be used at all after such benefits have been in force prior to the contest for a period of two years during the lifetime of the person to whom the statement applies.

B. Assignment

This certificate may not be assigned by you. Your benefits may not be assigned prior to a loss.

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C. Refund to Us for Overpayment of Benefits

If we pay Dental Expense Benefits to you for expenses incurred on your own account or on account of a Dependent, and it is found that we paid more Dental Expense Benefits to you than we should have paid because:

1. all or some of those expenses were not paid for by the

Covered Persons in your Family; or

2. any Covered Person in your Family was repaid for all or some of those expenses by a source other than from:

a. an insurer under a policy of insurance issued to you in

your name; and

b. an insurer under a policy of insurance issued to a Covered Person in your Family who ordinarily lives in your home; and

c. us;

we will have the right to a refund from you. The amount of the refund is the difference between:

1. the amount of Dental Expense Benefits paid by us for those

expenses; and

2. the amount of Dental Expense Benefits which should have been paid by us for those expenses.

However, at our option, we may recover the excess amount by reducing or offsetting any future benefits payable to such person by the amount of the overpayment.

D. Additional Provisions

1. The benefits under This Plan do not at any time provide paid-up insurance, or loan or cash values.

2. No agent has the authority:

a. to accept or to waive the required proof of a claim; nor

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b. to extend the time within which a proof must be given to us.

Form G.23000-B1

DEFINITIONS OF CERTAIN TERMS USED HEREIN "Actively at Work" or "Active Work" means that you are performing all of the material duties of your job with the Employer where these duties are normally carried out. If you were Actively at Work on your last scheduled working day, you will be deemed Actively at Work: 1. on a scheduled non-working day; 2. provided you are not disabled. "Covered Person" means an Employee or a Dependent on whose account benefits are in effect under This Plan. "Dependent" means your spouse or your unmarried natural child except for: 1. a person who is in the military or like forces of any country or of

any subdivision of a country; 2. a person who lives outside the United States or Canada; 3. a child who:

a. is 19 years of age or older and who is employed on a full-time basis; or

b. is 19 years of age or older and who is not a full-time student

at an approved school, as determined by the Employer; or c. is 25 years of age or older.

However, if you reside in Texas, the limiting age for children and grandchildren will not be less than 25 regardless of student status or military service status. Grandchildren must be living with you and

6

dependent on you for financial support. Please note, if you reside in New Mexico, the limiting age for children will not be less than 25 regardless of student status. If a Dependent child is a Covered Person on the day before that child has reached the applicable age limit, that child will continue to be a Dependent after the age limit as long as:

a. that child is and remains unable to work in self-sustaining employment because of:

i. physical handicap; or

ii. mental illness, developmental disability, or mental

retardation, as defined in the Mental Hygiene Law of New York State; and

b. that child is and remains chiefly dependent upon you for

support; and

c. that child is and remains a Dependent, as defined, except for the age limit; and

d. you give us proof, when we ask for it, that the child is and

remains so unable to work and dependent upon you since the age limit. We will not ask for proof more than once a year. The proof must be satisfactory to us.

Subject to the same conditions which apply to a natural child, child also includes:

a. a child who is supported solely by you and permanently living in the home of which you are the head; and

b. a child who is legally adopted; and

c. a stepchild, including the child of a Domestic Partner, who

lives in your home provided the natural parent's signature, approving such coverage, is included on the enrollment form.

"Dependent Benefits" mean the benefits which are provided on account of a Dependent under This Plan.

7

"Doctor" means a person who is legally licensed to practice medicine. A licensed practitioner will be considered a Doctor if: 1. there is a law which applies to This Plan and that law requires that

any service performed by such a practitioner must be considered for benefits on the same basis as if the service were performed by a Doctor; and

2. the service performed by the practitioner is within the scope of his

or her license. "Domestic Partner" means each of two people, one of whom is an Employee of the Employer who represent themselves publicly as each other's domestic partner and have:

1. registered as domestic partners or members of a civil union with a

government agency or office where such registration is available; or

2. submitted a domestic partner affidavit to the Employer.

The domestic partner affidavit must be notarized signed by both parties, and establish that:

1. each person is 18 years of age or older;

2. neither person is married;

3. neither person has had another domestic partner within 24

months prior to the enrollment date for insurance for the Domestic Partner under the Group Policy;

4. they have shared the same residence for at least 12 months prior

to the date they enroll for insurance for the Domestic Partner under the Group Policy;

5. they are not related by blood in a manner that would bar their

marriage in the jurisdiction in which they reside;

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6. they have an exclusive mutual commitment to share the responsibility for each other's welfare and financial obligations which commitment existed for at least 24 months prior to the date they enroll for insurance for the Domestic Partner under the Group Policy, and such commitment is expected to last indefinitely; and

7. 2 or more of the following exist as evidence of joint responsibility

for basic financial obligations:

a. a joint mortgage or lease; and

b. designation of the Domestic Partner as beneficiary for life insurance or retirement benefits; joint wills or designation of the Domestic Partner as executor and/or primary beneficiary; and

c. designation of the Domestic Partner as durable power of

attorney or health care proxy; and

d. ownership of a joint bank account, joint credit cards; and

e. other evidence of joint financial responsibility; and

f. other evidence of economic interdependence. The Employer will review the domestic partner affidavit and determine whether to accept the request to insure the Domestic Partner. The Employer will inform the Employee of its decision. "Employee" means a person who is employed and paid for services by the Employer on a full-time basis. Employee also means a person who retired from the Employer, as determined by the Employer. "Employer" means an entity participating in the MTA Consolidated Managerial Plan, which provides Dental Expense Benefits for its Employees. "Family" means you and your Dependents. "No Fault Law" means a motor vehicle liability law or other similar law which requires that benefits be provided for personal injury without regard to fault.

9

"Occupational Injury" means an injury which happens in the course of any work performed by the Covered Person for wage or profit. "Occupational Sickness" means a sickness which entitles the Covered Person to benefits under a worker's compensation or occupational disease law. "Personal Benefits" mean the benefits which are provided on account of an Employee under This Plan. "Spouse" means your lawful spouse. The term also includes your Domestic Partner. "This Plan" means the Group Policy which is issued by us to provide Personal Benefits and Dependent Benefits. "We", "us" and "our" mean Metropolitan. "You" and "your" mean the Employee who is a Covered Person for Personal Benefits. They do not include a Dependent of the Employee.

Form G.23000-A

ELIGIBILITY FOR BENEFITS Personal Benefits Eligibility Date 1. Applicable to Active Employees Other Than Employees of

Long Island Bus

Your Personal Benefits Eligibility Date is the later of:

a. January 1, 2008; and b. the first of the month coincident with or next following the date

you become an Employee of the Employer.

10

2. Applicable to Active Employees of Long Island Bus



you complete 6 months of continuous service as an Employee.

3. Applicable to Employees Who Retired On or After

December 1, 1996, under Long Island Rail Road, as determined by the Employer



you become a retired Employee of the Employer.

4. Applicable to Employees Who Retired Prior to January 1, 1997, under the New York City Transit Authority, as determined by the Employer

Your Personal Benefits Eligibility Date is January 1, 2008.

5. Applicable to All Other Employees Who Retired, as

determined by the Employer



you become a retired Employee of the Employer.

11

Dependent Benefits Eligibility Date Your Dependent Benefits Eligibility Date is the later of your Personal Benefits Eligibility Date and the date you first acquire a Dependent.

Form G.23000-C

EFFECTIVE DATES OF PERSONAL BENEFITS 1. Applicable to Active Employees Your Personal Benefits will become effective on your Personal Benefits Eligibility Date provided you are then Actively at Work as an Employee. If you are not then Actively at Work as an Employee, your Personal Benefits will become effective on the date of your return to Active Work as an Employee. 2. Applicable to Retired Employees Your Personal Benefits will become effective on your Personal Benefits Eligibility Date.

Form G.23000-D1

12

EFFECTIVE DATES OF DEPENDENT BENEFITS

A. Effective Date

Your Dependent Benefits will become effective on the later of:

1. your Dependent Benefits Eligibility Date; and 2. the effective date of your Personal Benefits.

On the effective date of your Dependent Benefits you will be insured for Dependent Benefits for all persons who are then your Dependents.

B. New Dependents

Dependent Benefits with respect to a person who becomes your Dependent while you are insured for Dependent Benefits will be effective on the date such person becomes your Dependent.

Form G.23000-D2

DENTAL EXPENSE BENEFITS A. DEFINITIONS

"Covered Dental Expense" means:

1. For In-Network Benefits

The charges based on the Preferred Dentist Program Maximum Allowed Charges for the types of dental services shown in section C. These services must be:

a. performed or prescribed by a Dentist who is a

Participating Provider; and

13

b. necessary (see NOTICES) as determined by Metropolitan in terms of generally accepted dental standards.

No more than the Maximum Allowed Charge for the types of dental services shown in section C will be covered by the Dental Expense Benefits. The Maximum Allowed Charge is the lower of:

a. the amount charged by the Participating Provider for

the service or supply; and

b. the maximum amount that the Participating Provider agreed with us to charge for that service or supply. This maximum amount is specified or based on the amounts specified in the Preferred Dentist Program Maximum Allowed Charges.

2. For Out-of-Network Benefits

The charges for the types of dental services shown in section C. These services must be:

a. performed or prescribed by a Dentist who is not a

Participating Provider; and

b. necessary (see NOTICES) as determined by Metropolitan in terms of generally accepted dental standards.

No more than the Reasonable and Customary Charge for the types of dental services shown in section C will be covered by the Dental Expense Benefits. The Reasonable and Customary Charge is the lowest of: a. the Dentist's actual charge for the services or supplies

(or, if the provider of the service or supplies is not a Dentist, such other provider's actual charge for the services or supplies); or

b. the usual charge by the Dentist or other provider of the

services or supplies for the same or similar services or supplies; or

14

c. the usual charge of other Dentists or other providers in the same geographic area equal to the 90 percentile of charges as determined by MetLife based on charge information for the same or similar services or supplies maintained in MetLife’s Reasonable and Customary Charge record. Where MetLife determines that there is inadequate charge information maintained in MetLife’s Reasonable and Customary Charge records for the geographic area in question, this will be determined based on actuarially sound principles.

An example of how the 90th percentile is calculated is to assume one hundred (100) charges for the same service are contained in MetLife’s Reasonable and Customary Charge records. These one hundred (100) charges would be sorted from lowest to highest charged amount and numbered 1 through 100. The 90th percentile of charges is the charge that is greater than or equal to the charge numbered 90.

With respect to In-Network Benefits and Out-of-Network Benefits, there may be more than one way to treat a dental problem. If, in our view, an adequate method or material which costs less could have been used, the Dental Expense Benefits will be based on the method or material which costs less. The rest of the cost will not be a Covered Dental Expense. See section E for examples that show how this works.

"Deductible Amount" means the amount shown in the SCHEDULE OF BENEFITS. The Deductible Amount is an annual amount.

The Out-of-Network Deductibles during any one Dental Expense Period will not apply to Out-of-Network Covered Dental Expenses for your Family after Covered Dental Expenses have been incurred for Covered Persons in your Family and the sum of In-Network Covered Dental Expenses and Out-of-Network Covered Dental Expenses equal the Out-of-Network Family Deductible Amount.

"Dental Expense Period" means a period which starts on any January 1 and ends on the next December 31.

15

"Dentist" means a person licensed by law to practice dentistry. A type of dental service which is performed or prescribed by a Doctor will be considered for Dental Expense Benefits as if it were performed or prescribed by a Dentist.

"Covered Percentage" means the percentage or percentages shown in the SCHEDULE OF BENEFITS.

"In-Network Benefits" means the Dental Expense Benefits provided under This Plan for covered dental services that are provided by a Dentist who is a Participating Provider.

"Out-of-Network Benefits" means the Dental Expense Benefits provided under This Plan for covered dental services that are not provided by a Dentist who is a Participating Provider.

"Preferred Dentist Program Maximum Allowed Charges" means our fee agreement with a Participating Provider in which such Participating Provider has agreed to accept a schedule of maximum fees as payment in full for services rendered.

"Preferred Dentist Program" means our program to offer a Covered Person the opportunity to receive dental care from Dentists who are designated by us as Participating Providers. When dental care is given by Participating Providers, the Covered Person will generally incur less out-of-pocket cost for the services rendered.

"Participating Provider" means a Dentist who has been selected by us for inclusion in the Preferred Dentist Program. These Participating Providers agree to accept our Preferred Dentist Program Maximum Allowed Charges as payment in full for services rendered.

"Non-Participating Provider" means a Dentist who is not a Participating Provider.

"Preferred Dentist Program Directory" means the list which consists of selected Dentists who:

1. are located in the Covered Person's area; and

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2. have been selected by us to be Participating Providers and part of the Preferred Dentist Program. These Participating Providers agree to accept our Preferred Dentist Program Maximum Allowed Charges as payment in full for services rendered.

The list will be periodically updated.

B. COVERAGE

1. When Benefits May Be Payable

We will pay Dental Expense Benefits if you incur Covered Dental Expenses:

a. for a Covered Person during a Dental Expense Period;

and

b. while you are covered for the Dental Expense Benefits for that Covered Person; and

c. the In-Network Covered Dental Expenses are more

than the In-Network Deductible Amount.

We will also pay Dental Expense Benefits if you incur Out-of-Network Covered Dental Expenses:

a. for a Covered Person during a Dental Expense Period;

and

b. while you are covered for the Dental Expense Benefits for that Covered Person; and

c. the sum of the In-Network Covered Dental Expenses

and Out-of-Network Covered Dental Expenses are more than the Out-of-Network Deductible Amount.

An expense is "incurred" on the date the type of dental service for which the charge is made is completed.

17

2. How Benefits Are Determined

Benefits will be equal to the Covered Percentage of those Covered Dental Expenses which are more than the Deductible Amount. An expense is “incurred” on the date the type of dental service for which the charge is made is completed, except for purposes of applying the Deductible Amount. The Deductible Amount will be applied based on when Dental Expense Benefit claims for Covered Dental Expenses are processed by us. The Deductible Amount will be applied to Covered Dental Expenses in the order that Dental Expense Benefit claims for Covered Dental Expenses are processed by us, regardless of when a Covered Dental Expense is “incurred”. When several Covered Dental Expenses are incurred on the same date and Dental Expense Benefits for the Covered Dental Expenses are claimed as part of the same claim, the Deductible Amount is applied based on the Covered Percentage applicable to each Covered Dental Expense. The Deductible Amount will be applied in the order of highest Covered Percentage to lowest Covered Percentage.

However:

a. The sum of all benefits for all Covered Dental

Expenses incurred for a Covered Person during any one Dental Expense Period will not be more than the Maximum Benefit For One Dental Expense Period shown in the SCHEDULE OF BENEFITS.

b. Orthodontic Covered Services - Orthodontic

treatment generally consists of initial placement of an appliance and a specified number of periodic follow-up visits as initially requested by the Dentist. Orthodontic treatment also includes other services required for the orthodontic treatment such as transseptal fibrotomy and extractions of certain teeth.

Upon the initial placement of the appliance, which may include other services such as the initial workup, we will pay an amount not to exceed 20% of the Covered

18

Expense times the Covered Percentage for Orthodontic Treatment.

After the initial placement of the orthodontic appliance we will pay any remaining benefit during the course of the orthodontic treatment (including periodic follow-up visits) as follows:

i. The amount payable during the scheduled course

of the orthodontic treatment will be the lower of:

(a) the amount of the Covered Dental Expense times the Covered Percentage for Orthodontia; and

(b) the remaining amount of the Aggregate

Maximum Benefit for Orthodontic Treatment (For All Dental Expense Periods).

ii. We will divide the benefit payable for the course

of the orthodontic treatment by the number of months in the scheduled course of the orthodontic treatment (but no more than 24 months). Benefits will be payable monthly.

Benefits will only be payable during the scheduled course of the orthodontic treatment if:

i. Dental Expense Benefits are in effect for the

person receiving the orthodontic treatment; and

ii. proof is given to us that the orthodontic treatment is continuing.

For minor orthodontia services that are performed in one visit and do not require follow-up visits, we will pay the amount of the Covered Dental Expense times the Covered Percentage for Orthodontia.

The sum of all benefits for all Covered Dental Expenses incurred for a Covered Person for orthodontic treatment, will not be more than the applicable Aggregate Maximum Benefit for Orthodontic Treatment as shown in the

19

SCHEDULE OF BENEFITS. This includes any services required for orthodontia received prior or related to the initial placement of an orthodontia appliance.

Benefits For Orthodontic Services Begun Prior To This Dental Insurance - If the initial placement of the appliance was made prior to these Dental Expense Benefits being in effect, no benefits will be payable under these Dental Expense Benefits for the initial placement of the appliance.

If periodic follow-up visits commenced prior to these Dental Expense Benefits being in effect: i. the number of months for which benefits are

payable based on the scheduled course of orthodontic treatment will be reduced by the number of months of treatment performed before these Dental Expense Benefits were in effect; and

ii. the total amount of the benefit payable that we

would have normally provided for treatment which was started while these Dental Expense Benefits were in effect will be reduced proportionately.

In order to determine what are the amounts of Covered Dental Expenses, we may ask for X-rays and other diagnostic and evaluative materials. If they are not given to us, we will determine Covered Dental Expenses on the basis of the information which is available to us. This may reduce the amount of benefits which otherwise would have been payable.

3. How the Preferred Dentist Program Works

Free Choice Of A Dentist:

A Covered Person is always free to choose the services of a Dentist who is either:

a. a Participating Provider; or

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b. a Non-Participating Provider.

Benefits under This Plan will be determined and paid in either case, except that the Covered Person will generally incur less out-of-pocket cost if a Participating Provider is chosen.

C. DENTAL SERVICES WHICH MAY BE COVERED DENTAL

EXPENSES

1. Type A Expenses

a. Oral exams but not more than twice in a Dental Expense Period.

b. Full mouth or panoramic X-rays but not more than

once every 36 months.

c. Bitewing X-rays but not more than twice in a Dental Expense Period.

d. Intraoral-periapical X-rays and other X-rays not

specified above. e. Cleaning of teeth (oral prophylaxis) but not more than

twice in a Dental Expense Period. f. Pulp vitality tests, diagnostic casts, and bacteriological

studies for determination of pathologic agents. g. Topical fluoride treatment for a Dependent child up to

19 years of age but not more than twice in a Dental Expense Period.

h. Emergency palliative treatment to relieve tooth pain. i. For Dependent child up to 19 years of age, space

maintainers.

21

j. For Dependent child up to 14 years of age, sealants which are applied to non-restored, non-decayed, first and second permanent molars, once per tooth for all Dental Expense Periods.

k. Tests for oral cancer screening but not more than

once in a 12 month period.

2. Type B Expenses a. Initial placement of amalgam or composite fillings.

b. Replacement of an existing amalgam or composite

fillings.

c. Sedative fillings.

d. Repair or re-cementing of Cast Restorations.

e. Pulp capping (excluding final restoration) and therapeutic pulpotomy (excluding final restoration).

f. Pulp therapy and apexification/recalcification.

g. Treatment of periodontal disease and other diseases

of the gums and tissues of the mouth.

h. Oral surgery except as mentioned elsewhere.

i. Extractions of unimpacted teeth and removal of exposed roots.

j. Extractions of impacted teeth.

k. Root canal treatment.

l. General anesthesia or intravenous sedation in

connection with oral surgery, extractions or other Covered Services, when We determine such anesthesia is necessary in accordance with generally accepted dental standards.

m. Consultations.

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n. Injections of therapeutic drugs.

o. Local chemotherapeutic agents.

p. Repair of Dentures. Dentures means fixed partial dentures (bridgework),

removable partial dentures and removable full dentures.

q. Relinings and rebasings of existing removable

Dentures:

i. if at least 6 months have passed since the installation of the existing removable Denture; and

ii. not more than once in any 36 month period.

r. Adjustments of Dentures, if at least 6 months have

passed since the installation of the Denture.

3. Type C Expenses a. Initial installation of Cast Restorations.

Cast Restoration means an inlay, onlay, or crown.

b. Replacement of any Cast Restorations with the same

or a different type of Cast Restoration but not more than one replacement for the same tooth within 60 months.

c. Prefabricated stainless steel crown or prefabricated

resin crown, in either case, only for primary teeth but not more than once in any 60 month period.

d. Core buildup, labial veneers and post and cores, but

not more than one of each service for a tooth in a period of 60 months.

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e. Initial installation of full or removable Dentures when needed to replace natural teeth that are lost while the Covered Person receiving such benefits was insured for Dental Expense Benefits under this certificate.

f. Replacement of a non-serviceable Denture if such

Denture was installed more than 60 months prior to replacement.

g. Replacement of an immediate, temporary full Denture

with a permanent full Denture if the immediate, temporary full Denture cannot be made permanent and such replacement is done within 12 months of the installation of the immediate, temporary full Denture.

h. Adding teeth to an existing partial removable denture or

to bridgework when needed to replace one or more natural teeth removed after the existing denture or bridgework was installed.

i. Implants but no more than once for the same tooth

position in a 60 month period.

j. Implant support prosthetics but no more than once for the same tooth position in a 60 month period.

k. Repair of implants, but not more than once in a 12

month period.

4. Type D Expenses Orthodontia, including appliance therapy for a

Dependent child under age 19.

The Aggregate Maximum Benefit for orthodontia is shown in the SCHEDULE OF BENEFITS.

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D. EXCLUSIONS - DENTAL SERVICES WHICH ARE NOT COVERED DENTAL EXPENSES

1. Services or supplies received by a Covered Person before

the Dental Expense Benefits start for that person.

2. Services not performed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for:

a. scaling and polishing of teeth; or

b. fluoride treatments.

3. Cosmetic surgery or supplies. However, any such surgery

or supply will be covered if:

a. it otherwise is a Covered Dental Expense; and

b. it is required for reconstructive surgery which is incidental to or follows surgery which results from a trauma, an infection or other disease of the involved part; or

c. it is required for reconstructive surgery because of a

congenital disease or anomaly of a Dependent child which has resulted in a functional defect.

4. Replacement of a lost, missing or stolen crown, bridge or

denture.

5. Services or supplies which are covered by any workers' compensation laws or occupational disease laws.

6. Services or supplies which are covered by any employers'

liability laws.

7. Services or supplies which any employer is required by law to furnish in whole or in part.

8. Services or supplies received through a medical

department or similar facility which is maintained by the Covered Person's employer.

25

9. Repair or replacement of an orthodontic appliance.

10. Services or supplies received by a Covered Person for which no charge would have been made in the absence of Dental Expense Benefits for that Covered Person.

11. Services or supplies for which a Covered Person is not

required to pay.

12. Services or supplies which are deemed experimental in terms of generally accepted dental standards.

13. Services or supplies received as a result of dental disease,

defect or injury due to an act of war, or a warlike act in time of peace, which occurs while the Dental Expense Benefits for the Covered Person are in effect.

14. Adjustment of a denture or a bridgework which is made

within 6 months after installation by the same Dentist who installed it.

15. Any duplicate appliance or prosthetic device.

16. Use of material or home health aids to prevent decay, such

as toothpaste or fluoride gels, other than the topical application of fluoride.

17. Instruction for oral care such as hygiene or diet.

18. Periodontal splinting.

19. Temporary or provisional restorations.

20. Temporary or provisional appliances.

21. Services or supplies to the extent that benefits are

otherwise provided under This Plan or under any other plan which the Employer (or an affiliate) contributes to or sponsors.

22. Appliances or treatment for bruxism (grinding teeth),

including but not limited to occlusal guards and night guards.

26

23. Myofunctional therapy or correction of harmful habits.

24. Initial installation of a denture or bridgework to replace one or more natural teeth lost before the Dental Expense Benefits started for the Covered Person or as a replacement for congenitally missing natural teeth.

25. Charges for broken appointments.

26. Charges by the Dentist for completing dental forms.

27. Sterilization supplies.

28. Services or supplies furnished by a family member.

29. Treatment of temporomandibular joint disorders.

E. EXAMPLES OF ALTERNATE BENEFITS

Dental Expense Benefits will be based on the materials and method of treatment which cost the least and which, in our view, meet generally accepted dental standards. 1. Amalgam and Composite Fillings

When an amalgam filling and a composite filling are both professionally acceptable methods for filling a molar, we will base our benefit determination upon the amalgam filling which is the less costly service.

2. Inlays, Onlays, Crowns and Gold Foil

If a tooth can be repaired to our satisfaction according to generally accepted dental standards by a less costly method than an inlay, onlay, crown or gold foil, Dental Expense Benefits will be based on the adequate method of repair which costs the least.

3. Crowns, Pontics, and Abutments

Veneer materials may be used for front teeth or bicuspids. However, Dental Expense Benefits will be based on the adequate veneer materials which cost the least.

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4. Bridgework and Dentures

Dental Expense Benefits will be based on the adequate method of treating the dental arch which costs the least. In some cases removable dentures may serve as well as fixed bridgework. If dentures are replaced by fixed bridgework, the Dental Expense Benefits will be based on the cost of a replacement denture unless adequate results can only be achieved with fixed bridgework.

These are not the only examples of alternate benefits. To find out how much your Dental Expense Benefits will be, see section F.

F. PRE-DETERMINATION OF BENEFITS

If a dental bill is expected to be $200 or more, before the Dentist starts the treatment, a Covered Person can find out what Dental Expense Benefits will be paid under This Plan. To do this, the Covered Person should send a claim form to us in which the Dentist tells us: 1. the work to be done; and

2. what the cost will be.

We will then tell the Covered Person what Dental Expense Benefits This Plan may pay. If the Covered Person does not use this method to find out what Dental Expense Benefits This Plan may pay, our decision will be final and binding with regard to what are Covered Dental Expenses and what Dental Expense Benefits This Plan may pay.

This method should not be used for:

1. emergency treatment; or

2. routine oral exams; or

3. X-rays, scaling and polishing, and fluoride treatments; or

4. dental services which cost less than $200.

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G. IMPACT OF GOVERNMENT PLANS ON DENTAL EXPENSE BENEFITS

To the extent that services or supplies, or benefits for them, are available to a Covered Person under a Government Plan, as defined below, they will not be considered for Dental Expense Benefits under This Plan. This provision will apply whether or not the Covered Person is enrolled for all Government Plans for which that Covered Person is eligible.

This provision will not apply to a Government Plan if that Government Plan requires that Dental Expense Benefits under This Plan be paid first.

A "Government Plan" is any plan, program or coverage, other than Medicare:

1. which is established under the laws or the regulations of

any government; or

2. in which any government participates other than as an employer.

H. DENTAL EXPENSE COVERAGE AFTER BENEFITS END

No benefits will be payable for Covered Dental Expenses incurred by a Covered Person after the Dental Expense Benefits for that person end. This will apply even if we have pre-determined benefits for dental services. However, benefits for Covered Dental Expenses incurred for a Covered Person for the following services will be paid after Dental Expense Benefits end:

1. For a prosthetic device if:

a. the Dentist prepared the abutment teeth and made

impressions while Dental Expense Benefits for the Covered Person were in effect; and

b. the device is installed within 31 days after the date the

Dental Expense Benefits end; or

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2. For a crown if:

a. the Dentist prepared the tooth for the crown while the Dental Expense Benefits for the Covered Person were in effect; and

b. the crown is installed within 31 days after the date the

Dental Expense Benefits end; or

3. For root canal therapy if:

a. the Dentist opened into the pulp chamber while the Dental Expense Benefits for the Covered Person were in effect; and

b. the treatment is finished within 31 days after the date

the Dental Expense Benefits end. I. PAYMENT OF BENEFITS

Dental Expense Benefits will be paid to:

1. the Dentist, if you have assigned benefits directly to the Dentist; or

2. you, in all other cases.

We will pay benefits when we receive satisfactory written proof of your claim. Proof must be given to us not later than 90 days after the end of the Dental Expense Period in which the Covered Dental Expenses were incurred. If proof is not given on time, the delay will not cause a claim to be denied or reduced as long as proof is given as soon as possible.

Form G.23000-13E

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WHEN BENEFITS END

A. All of your benefits will end on the last day of the calendar month in

which your employment ends (unless you continue to be covered as a retired Employee. Your employment ends when you cease Active Work as an Employee. However, for the purpose of benefits, the Employer may deem your employment to continue for certain absences. See CONDITIONS UNDER WHICH YOUR ACTIVE WORK IS DEEMED TO CONTINUE.

B. If This Plan ends in whole or in part, your benefits which are

affected will end. C. Your Dependent Benefits will end on the earlier of:

1. the date that the Dependent ceases to be your Dependent; or

2. the date of your death. The end of any type of benefits on account of a Covered Person will not affect a claim which is incurred before those benefits ended. The Dental Expense Benefits for a Covered Person may be continued in accordance with the Federal law called COBRA. See the pages entitled NOTICE OF YOUR RIGHT AND YOUR DEPENDENTS' RIGHT TO CONTINUE DENTAL BENEFITS.

Form G.23000-F

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CONDITIONS UNDER WHICH YOUR ACTIVE

WORK IS DEEMED TO CONTINUE If you are not Actively at Work as an Employee because of a situation set forth below, the Employer may deem you to be in Active Work as an Employee only for the purpose of continuing your employment and only for the periods specified below in order that certain of your benefits under This Plan may be continued. All such benefits will be subject to prior cessation as set forth in WHEN BENEFITS END. In any case, the benefits will end on: 1. the date the Employer notifies us that your benefits are not to be

continued; or 2. the end of the last period for which the Employer has paid

premiums to us for your benefits. Your Sickness or Injury, Your Leave of Absence, Your Lay Off With respect to all Personal Benefits and all Dependent Benefits, the period determined in accordance with the Employer's general practice for an Employee in your job class. However, in the event the leave qualifies under the Family and Medical Leave Act of 1993 (FMLA) or a similar state law, the period cannot be longer than the leave required by the law. If a leave qualifies under more than one such law, the period cannot be longer than the longest leave permitted under any of the laws.

Your Retirement With respect to all Personal Benefits and Dependent Benefits during your period of retirement, as determined by the Employer.

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CONTINUATION OF DENTAL EXPENSE BENEFITS FOR YOUR DEPENDENTS DURING A MEDICAL LEAVE OF ABSENCE FROM SCHOOL You may continue Dental Expense Benefits for a child who ceases to be a full-time student if such child is required because of illness, to take a medical leave of absence from school. Dental Expense Benefits may be continued during the medical leave of absence for a period of up to 12 months. During this period you must continue to pay any premiums you were required to pay for such Dental Expense Benefits. This continuation will end upon the earliest of: 1. 12 months after the date the leave of absence begins; 2. the date you fail to pay any required premium when due; 3. the date the medical leave of absence ends; 4. the date the child fails to satisfy the definition of Dependent for

any reason other than status as a full-time student; or 5. the date your Dental Expense Benefits end. You must send us Proof documenting the illness and medical necessity of the leave of absence. Proof includes furnishing us with a Physician's statement certifying the medical necessity of the leave.

Form G.23000-L

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COORDINATION OF BENEFITS

A. Definitions

"Plan" means a plan which provides benefits or services for, or by reason of, dental care and which is:

1. a group insurance plan; or

2. a group blanket plan, but not including school accident-type

coverages covering students in:

a. a grammar school;

b. a high school; or

c. a college;

for accident only (including athletic injuries) either on a 24 hour basis or on a "to and from school basis"; or

3. a group practice plan; or

4. a group service plan; or

5. a group prepayment plan; or

6. any other plan which covers people as a group; or

7. a governmental program or coverage required or provided by

any law, except Medicaid, but including any motor vehicle No Fault coverage which is required by law.

Each policy, contract or other arrangement for benefits or services will be treated as a separate Plan. Each part of such a Plan which reserves the right to take the benefits or services of other Plans into account to determine its benefits will be treated separately from those parts which do not.

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"This Plan" means only those parts of This Plan which provide benefits or services for dental care. The provisions of This Plan which limit benefits based on benefits or services provided under: 1. Government Plans; or

2. Plans which the Employer (or an affiliate) contributes to or

sponsors; will not be affected by these Coordination of Benefits provisions.

For the purpose of applying these provisions, if both spouses are covered as Employees under This Plan, each spouse will be considered as covered under separate Plans.

"Primary Plan/Secondary Plan" When This Plan is a Primary Plan, it means that This Plan's benefits are determined:

1. before those of the other Plan; and

2. without considering the other Plan's benefits. When This Plan is a Secondary Plan, it means that This Plan's benefits:

1. are determined after those of the other Plan; and

2. may be reduced because of the other Plan's benefits.

When there are more than two Plans covering the person, This Plan may be a Primary Plan as to one or more of those other Plans and may be a Secondary Plan as to a different Plan or Plans.

"Allowable Expense" means any reasonable and customary charge which meets all of the following tests:

1. it is a charge for an item of necessary dental expense; and

2. it is an expense which a Covered Person must pay; and

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3. it is an expense at least a part of which is covered under at least one of the Plans which covers the person for whom claim is made.

When a Plan provides fixed benefits for specified events or conditions rather than benefits based on expenses, any benefits under that Plan will be deemed to be Allowable Expenses.

When a Plan provides benefits in the form of services rather than cash payment, the reasonable cash value of each service rendered will be deemed to be both an Allowable Expense and a benefit paid.

However, Allowable Expenses do not include:

a. expenses for services rendered because of:

1. an Occupational Sickness; or

2. an Occupational Injury.

b. any amount of benefits reduced under a Primary Plan

because the Covered Person does not comply with the Plan provisions. Examples of such provisions are those related to:

1. second surgical opinions;

2. precertification of admissions or services; and

3. preferred provider arrangements.

Only benefit reductions based upon provisions similar in purpose to those described in the prior sentence and which are contained in the Primary Plan may be excluded from Allowable Expenses. This provision will not be used by a Secondary Plan to refuse to pay benefits because a Health Maintenance Organization member has elected to have health care services provided by a non-HMO provider and the HMO, pursuant to its contract, is not obliged to pay for providing those services.

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"Claim Determination Period" means a period which starts on any January 1 and ends on the next December 31. However, a Claim Determination Period for any Covered Person will not include periods of time during which that person is not covered under This Plan.

"Custodial Parent" means a parent awarded custody by a court decree. In the absence of a court decree, it is the parent with whom the child resides more than half of the calendar year without regard to any temporary visitation.

B. Effect on Benefits

1. When there is a basis for a claim under This Plan and another Plan, This Plan is a Secondary Plan which has its benefits determined after those of the other Plan, unless:

a. the other Plan has rules coordinating its benefits with

those of This Plan; and

b. both those rules and This Plan's rules in subsection 3 of this Section B require that This Plan's benefits be determined before those of the other Plan.

2. If This Plan is a Secondary Plan, when the total Allowable

Expenses incurred for a Covered Person in any Claim Determination Period are less than the sum of:

a. the benefits that would be payable under This Plan

without applying this Coordination of Benefits provision; and

b. the benefits that would be payable under all other Plans

without applying Coordination of Benefits or similar provisions;

the benefits described in item 2(a) of this section B will be reduced. The sum of these reduced benefits plus all benefits payable for such Allowable Expenses under all other Plans will not exceed the total of the Allowable Expenses. Benefits payable under all other Plans include all benefits that would be payable if the proper claims had been given on time.

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When the benefits of This Plan are reduced as described above, each benefit is reduced in proportion. It is then charged against the benefit limits of This Plan.

3. Rules for Determining the Order in which Plans Determine

Benefits. When more than one Plan covers the person for whom Allowable Expenses were incurred, the order of benefit determination is:

a. Non-dependent/Dependent. The Plan which covers that

person other than as a dependent (for example, as an employee, member, subscriber or retiree) determines its benefits before the Plan which covers that person as a dependent; except that if the person is also a Medicare beneficiary, and as a result of the rules established by Title XVIII of the Social Security Act and implementing regulations, Medicare is:

i. Secondary to the Plan covering the person as a

dependent; and

ii. Primary to the Plan covering the person as other than a dependent (e.g., a retired person);

then the benefits of the Plan covering the person as a dependent are determined before those of the Plan covering that person as other than a dependent.

b. Child Covered under More than One Plan. When This

Plan and another Plan cover the same child as a dependent of different persons, called "parents":

i. the Primary Plan is the Plan of the parent whose

birthday is earlier in the year if:

1. the parents are married; 2. the parents are not separated (whether or not

they ever have been married); or 3. a court decree awards joint custody without

specifying that one party is responsible for providing health care coverage.

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For example, if one parent's birthday were January 8 and the other parent's birthday were March 3, then the Plan covering the parent with the January 8 birthday would determine its benefits before the Plan covering the parent with the March 3 birthday.

ii. if both parents have the same date of birth

(excluding year of birth), the Plan which covered the parent for the longer time determines its benefits before the Plan which covered the other parent for the shorter time.

iii. if the specific terms of a court decree state that one

of the parents is responsible for the child's healthcare expenses or healthcare coverage and the Plan of that parent has actual knowledge of those terms, that Plan is Primary. This paragraph does not apply with respect to any Claim Determination Period during which any benefits are actually paid or provided before that Plan has that actual knowledge of the terms of the court decree.

iv. if the parents are not married or are separated

(whether or not they have ever been married) or are divorced, the order of benefits is:

1. the Plan of the Custodial Parent;

2. the Plan of the spouse of the Custodial

Parent;

3. the Plan of the Non-Custodial Parent;

4. the Plan of the spouse of the Non-Custodial Parent.

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c. Active/Laid-off or Retired Employee. The Plan which covers that person as an active employee (or as that employee's dependent) is Primary to a Plan which covers that person as a laid-off or retired employee (or as that employee's dependent). If the Plan which covers that person has not adopted this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule shall not apply.

d. Continuation Coverage. The Plan which covers the

person as an active employee, member or subscriber (or as that employee's dependent) is Primary to a Plan which covers that person under a right of continuation pursuant to federal law (e.g., COBRA) or state law. If the Plan which covers that person has not adopted this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule d. shall not apply.

e. Longer/Shorter Time Covered. If none of the above rules

determines the order of benefits, the Plan which has covered the Employee for the longer time determines its benefits before the Plan which covered that person for the shorter time.

C. Right to Receive and Release Needed Information

Certain facts are needed to apply these Coordination of Benefits rules. We have the right to decide which facts we need. We may get facts from or give them to any other organization or person. We need not tell, nor get the consent of, any person or organization to do this. To obtain all benefits available, a claim should be filed under each Plan which covers the person for whom Allowable Expenses were incurred. Each person claiming benefits under This Plan must give us any facts we need to pay the claim.

D. Facility of Payment

A payment made under another Plan may include an amount which should have been paid under This Plan. If it does, we may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under This Plan. We will not have to pay that amount again. The term "payment made" includes providing benefits in the form of

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services, in which case "payment made" means reasonable cash value of the benefits provided in the form of services.

E. Right of Recovery

If the amount of the payments made by us is more than we should have paid under this Coordination of Benefits provision, we may recover the excess from one or more of:

1. the persons we have paid or for whom we have paid;

2. insurance companies; or

3. other organizations.

The "amount of the payment made" includes the reasonable cash value of any benefits provided in the form of services.

Form G.23000-N7

NOTICES This certificate is of value to you. It should be kept in a safe place. As soon as your benefits end, you should consult your Employer to find out what rights, if any, you may have to continue your protection. If you or your Dependents had coverage under a prior plan of benefits, please consult your Employer to determine if there are any additional provisions which affect your benefits under This Plan. The fact that a Dentist may recommend that a Covered Person receive a dental service does not mean: 1. that the dental service will be deemed to be necessary; or 2. that benefits under This Plan will be paid for the expenses of the

dental service.

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Metropolitan will make the decision as to whether the dental service: 1. is necessary in terms of generally accepted dental standards; and 2. is qualified for benefits under This Plan. PROCEDURES FOR CLAIM REVIEW INTERNAL PROCEDURES FOR CLAIM REVIEW BY METLIFE First Level of Review MetLife maintains a procedure by which a denied claim may be appealed. In the event a claim is denied, you can request a review of your claim. This request for review should be sent in writing to Group Claims Review, at the address of the MetLife office which processed the claim. This request should be sent to us within 60 days after you receive notice of denial of the claim. When requesting a review, please state the reason you believe the claim was improperly denied. You and your Dentist should submit any information that is appropriate such as diagnostic materials, x-rays, or narrative. Decisions on your appeal will be made no later than 60 days after receipt of the request for review. Second Level of Review If the appeal is not resolved to your satisfaction, you can appeal the action to second level of review for reconsideration. This second level of review is done through senior level consultants who make the final recommendations. Decisions on your appeal in the second level of review will be made no later than 60 days after receipt of the request for reconsideration. Please note, by undertaking a second level review you may foreclose your right to an external appeal as an external appeal must be filed within 45 days of the Final Adverse Determination of the first level review. EXTERNAL PROCEDURES FOR CLAIM REVIEW OUTSIDE OF METLIFE New York state law gives you the right to an external appeal when payment of benefits for dental services have been denied on the basis

42

that the services are not dentally necessary or that the services are experimental or investigational. If you have received a Final Adverse Determination after our first level of review, you can request an external appeal by completing an application form and sending it to the New York State Insurance Department within 45 days: • of when you received the Final Adverse Determination; or • of receiving written confirmation from us that the internal appeal

process has been waived. Final Adverse Determination means a written notification from us that your claim for dental benefits has been denied through our appeal process. You may obtain an application form or any additional information by calling us at 1-800-638-5433 or by calling the New York Insurance Department at 1-800-400-8882. You may also obtain an application or further information by visiting the New York Insurance Department's web site at www.ins.state.ny.us. Eligibility for an External Appeal To be eligible for an external appeal, payment of benefits for dental services must have been denied on the basis that the services are not dentally necessary or that the services are experimental or investigational and: • you must have received a Final Adverse Determination as a result

of our internal utilization review appeal process; or

• you and MetLife must have agreed to waive that appeal process. If you do not file a request for an external appeal with the state within this 45 day period, you will not be eligible for an external appeal. MetLife has two levels of internal appeals, you must file a request for external appeal within 45 days of your receipt of the Final Adverse Determination from our first level appeal process to be eligible for an external appeal. If services are denied as experimental or investigational, you must have a life-threatening or disabling condition or disease to be eligible

43

for an external appeal and your Dentist must complete the Attending Physician Attestation form and send the form to the New York Insurance Department. The Attending Physician Attestation form is included as part of the application form. You may only appeal a service or procedure that is a Covered Service under this certificate. The external appeal process may not be used to expand your dental coverage. Eligibility for an Expedited External Appeal If your attending Dentist attests that a delay in providing the treatment or service poses an imminent or serious threat to your health you may request an expedited appeal. When requesting an expedited appeal, make sure you give the Attending Physician Attestation form to your Dentist to complete. Your appeal will not be forwarded to the external appeal agent until your Dentist sends this attestation to the Insurance Department. Time Periods for External Appeals For standard appeals, the external appeal agent must make a determination within 30 days of receiving your request for an external review from the state. If additional information is requested, the external appeal agent has five additional business days to make a determination. For expedited appeals, the external appeal agent must make a determination within three days of receiving your request for an external review from the state. The Cost to You for an External Appeal We may charge you a fee of up to $50.00 for an external appeal. If We determine that the fee will pose a hardship, you will not be required to pay a fee. If the external appeal agent overturns the Final Adverse Determination, the fee will be refunded to you. Submission of Information If your case is determined to be eligible for external review, you will be notified of the certified external appeal agent assigned to review your

44

case. MetLife will send your dental and treatment records to the external appeal agent. When the external appeal agent reviews your case, the agent may request additional information from you or your Dentist. This information should be sent immediately to the external appeal agent. You and your Dentist can submit information even when the external appeal agent has not requested specific information. You must submit this information to the New York State Insurance Department within 45 days: • of when you received the Final Adverse Determination; or • of receiving written confirmation from us that the internal appeal

process has been waived. Once the external appeal agent makes a determination or your 45 day time period ends, you will not be able to submit additional information. The external appeal application contains a release of medical records provision that you must sign to authorize the release of medical and treatment records, including HIV, mental health and alcohol and drug abuse records to the certified external appeal agent assigned to review your appeal. Notification of a Decision When the external appeal agent has made the decision: • for standard appeals, you and MetLife will be notified in writing

within two business days; or • for expedited appeals, you and MetLife will be notified immediately

by telephone or fax. Written notification will follow. The decision of the external appeal agent is binding on you and MetLife.

45

Our Home Office is located at 200 Park Avenue, New York, New York 10166.

Form G.23000-E

THIS IS THE END OF THE CERTIFICATE. THE FOLLOWING IS ADDITIONAL INFORMATION.

NOTICE OF YOUR RIGHT AND YOUR DEPENDENTS'

RIGHT TO CONTINUE DENTAL BENEFITS When your employment terminates for any reason other than your gross misconduct, or if your hours worked are reduced so that your coverage terminates, you and your covered dependents may continue coverage under This Plan for a period of up to 18 months. However, if it is determined under the terms of the Social Security Act that you or your covered dependent is disabled within 60 days after your termination of employment or reduction of hours, you and your covered dependents may continue your dental coverage under This Plan for an additional 11 months after the expiration of the 18 month period. During the additional 11 months of coverage, your cost for that coverage will be approximately 50% higher than it was during the preceding 18 months. In addition, if you should die, become divorced or legally separated, or become eligible for Medicare, your covered dependents may continue coverage under This Plan for up to 36 months. Also, your covered children may continue coverage under This Plan for up to 36 months after they no longer qualify as covered dependents under the terms of This Plan. During the continuation period, a child of yours that is (1) born; (2) adopted by you; or (3) placed with you for adoption, will be treated as if the child were a covered dependent at the time coverage was lost due to an event described above. This continuation will terminate on the earliest of: 1. the end of the 18, 29 or 36 month continuation period, as the case

may be;

2. the date of expiration of the last period for which the required payment was made;

3. the date, after a Covered Person elects to continue coverage, that

the Covered Person first becomes covered under another group health plan as long as the new plan does not contain any exclusion or limitation with respect to any preexisting condition on the Covered Person;

4. the date This Plan is cancelled. Notice will be given when you or your covered dependents become entitled to continue coverage under the Plan. You, or they, will then have at least 60 days to elect to continue coverage. However, you or your covered spouse or your covered child must notify the Employer within 60 days in the event you receive a determination of disability under the terms of the Social Security Act, you become divorced or legally separated, or when your dependent child no longer qualifies as a covered dependent under This Plan. Any person who elects to continue coverage under the Plan must pay the full cost of that coverage (including both the share you now pay and the share your Employer now pays), plus any additional amounts permitted by law. Your payments for continued coverage must be made on the first day of each month in advance.

PRIVACY OF YOUR MEDICAL INFORMATION Notwithstanding any other Plan provision in this or other sections of this Plan, the Plan will operate in accordance with the HIPAA privacy laws and regulations as set forth in 45 CFR Parts 160 and 164, and as they may be amended ("HIPAA"), with respect to protected health information ("PHI") as that term is defined therein. The Plan Administrator and/or his or her designee retains full discretion in interpreting these rules and applying them to specific situations. All such decisions shall be given full deference unless the decision is determined to be arbitrary and capricious.

I. Permitted Uses and Disclosures of PHI by the Plan and the Plan Sponsor

The Plan and the Plan Sponsor are permitted to use and disclose PHI for the following purposes, to the extent they are not inconsistent with HIPAA: • For general plan administration, including policyholder service

functions, enrollment and eligibility functions, reporting functions, auditing functions, financial and billing functions, to assist in the administration of a consumer dispute or inquiry, and any other authorized insurance or benefit function.

• As required for computer programming, consulting or other work

done in respect to the computer programs or systems utilized by the Plan.

• Other uses relating to plan administration which are approved in

writing by the Plan Administrator or Plan Privacy Officer. • At the request of an individual, to assist in resolving claims the

individual may have with respect to benefits under the Plan.

II. Uses and Disclosures of PHI by the Plan and the Plan Sponsor for Required Purposes

The Plan and Plan Sponsor may use or disclose PHI for the following required purposes: • Judicial and administrative proceedings, in response to lawfully

executed process, such as a court order or subpoena. • For public health and health oversight activities, and other

governmental activities accompanied by lawfully executed process. • As otherwise may be required by law.

III. Sharing of PHI With the Plan Sponsor As a condition of the Plan Sponsor receiving PHI from the Plan, the plan documents have been amended to incorporate the following provisions, under which the Plan Sponsor agrees to: • Not use or further disclose PHI other than as permitted or required

by the plan documents in Section I and II above; • Ensure that any agents or subcontractors to whom it provides PHI

received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor;

• Not use or disclose PHI for employment-related actions or

decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor;

• Report to the Plan any use or disclosure of the information that is

inconsistent with the permitted uses or disclosures of which it becomes aware;

• Make PHI available to Plan participants for the purposes of the

rights of access and inspection, amendment, and accounting of disclosures as required by HIPAA;

• Make its internal practices, books and records relating to the use

and disclosure of PHI received from the Plan available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining compliance by the Plan with HIPAA;

• If feasible, return or destroy all PHI received from the Plan that the

sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible;

• Ensure that adequate separation between the Plan and Plan

Sponsor is established in accordance with the following requirements:

a. Employees to be Given Access to PHI: The following

employees (or class of employees) of the Plan Sponsor are the only individuals that may access PHI provided by the Plan:

Human Resources Personnel, as designated by the

appropriate MTA agency. b. Restriction to Plan Administration Functions: The access to

and use of PHI by the employees of the Plan Sponsor designated above will be limited to plan administration functions that the Plan Sponsor performs for the Plan.

c. Mechanism for Resolving issues of Noncompliance: If the Plan

Administrator or Privacy Officer determines that an employee of the Plan Sponsor designated above has acted in noncompliance with the plan document provisions outlined above, then the Plan Administrator or Privacy Officer shall take or seek to have taken appropriate disciplinary action with respect to that employee, up to and including termination of employment as appropriate. The Plan Administrator or Privacy Officer shall also document the facts of the violation, actions that have been taken to discipline the offending party and the steps taken to prevent future violations.

• Certify to the Plan, prior to the Plan permitting disclosure of PHI to

the Plan Sponsor, that the plan documents have been amended to incorporate the provisions in this section titled "Sharing of PHI With the Plan Sponsor".

IV. Participants Rights Participants and their covered dependents will have the rights set forth in the Plan's or its dental insurer's HIPAA Notice of Privacy Practices for Protected Health Information and any other rights and protections required under the HIPAA. The Notice may periodically be revised by the Plan or its dental insurer.

V. Privacy Complaints/Issues All complaints or issues raised by Plan participants or their covered dependents in respect to the use of their PHI must be submitted in writing to the Plan Administrator or the Plan's appointed Privacy Officer. A response will be made within 30 days of the receipt of the written complaint. In the event more time is required to resolve any issues this period can be extended to 90 days. The affected participant must receive written notice of the extension and the resolution of their complaint. The Plan Administrator or Privacy Officer shall have full discretion in resolving the complaint and making any required interpretations and factual determinations. The decision of the Plan Administrator or Privacy Officer shall be final and be given full deference by all parties.

VI. Security As a condition of the Plan Sponsor receiving electronic PHI (“ePHI”) from the Plan, the plan documents are hereby amended to incorporate the following provisions, under which the Plan Sponsor agrees to: • Implement administrative, physical, and technical

safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the ePHI that it creates, receives, maintains, or transmits on behalf of the Plan;

• Ensure that the adequate separation between the Plan and

the Plan Sponsor, which is required by the applicable section(s) of the Plan relating to the sharing of PHI with the Plan Sponsor, is supported by reasonable and appropriate security measures;

• Ensure that any agent, including a subcontractor, to whom it

provides ePHI agrees to implement reasonable and

appropriate security measures to protect the information; and

• Report to the Plan any security incident of which it becomes

aware. In this context, the term “security incident” means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in information systems such as hardware, software, information, data, applications, communications, and people.

DISCLOSURE STATEMENT - (NEW YORK)

METROPOLITAN LIFE INSURANCE COMPANY

Required Disclosure Statement

The insurance evidenced by this certificate provides dental insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department.

MTA HQ

Value Added Features:In addition to the health benefits your EyeMed program offers, members also enjoy additionalvalue-added features including:• Eye Care Supplies - Receive 20% off retail price for eye care supplies like cleaning cloths and solutions

purchased at network providers (not valid on doctor's services or contact lenses).• Laser Vision Correction - Save 15% off the retail price or 5% off the promotional price for LASIK or PRK

procedures.• Replacement Contact Lens Purchases - Visit www.eyemedcontacts.com to order replacement contact

lenses for shipment to your home at less than retail price.

Out-of-NetworkVision Care Services Member Cost Reimbursement

Exam with Dilation as Necessary $0 Copay Up to $40

Frames: $0 Copay, $90 Allowance; plus balance over $90 Up to $45

Standard Plastic Lenses:Single Vision $0 Copay Up to $40Bifocal $0 Copay Up to $60Trifocal $0 Copay Up to $60Lenticular $0 Copay Up to $150Standard Progressive $0 Copay Up to $180Premium Progressive $0 Copay, 80% of Charge less $120 Allowance Up to $180

Lens Options (paid by the member and added to the base price of the lens):Tint (Solid and Gradient) $0 Up to $25UV Coating $12 N/AStandard Scratch-Resistance $12 N/AStandard Polycarbonate - Adults $30 N/AStandard Polycarbonate - Children under 19 $30 N/AStandard Anti-Reflective $35 N/APolarized 20% off retail price N/AGlass $15 N/APhotochromatic - Glass $30 N/AOther Add-Ons and Services 20% off retail price N/A

Contact Lenses (allowance covers materials only):Conventional $0 Copay, $100 Allowance; plus balance over $100 Up to $100Disposables $0 Copay, $100 Allowance; plus balance over $100 Up to $100Medically Necessary $0 Copay, Paid in Full Up to $100

LASIK and PRK Vision Correction Procedures: 15% off retail price OR N/A5% off promotional pricing

Additional Pairs: Members also receive a 40% discount off complete pair eyeglass N/Apurchases and a 15% discount off conventional contact lenses once the

funded benefit has been used.

Frequency:Exam Once every calendar yearFrames Once every calendar yearStandard Plastic Lenses or Contact Lenses Once every calendar year

Additional Purchases and Out-of-Pocket Discount

Member will receive a 20% discount on remaining balance at Participating Providers beyond plan coverage; the discount does not applyto EyeMed’s Providers’ professional services or disposable contact lenses. Members also receive a 40% discount off complete pair eye-glass purchases and a 15% discount off conventional contact lenses once the funded benefit has been used.Benefits are not provided for services or materials arising from: Orthoptic or vision training, subnormal vision aids and any associatedsupplemental testing; Aniseikonic lenses; Medical and/or surgical treatment of the eye, eyes or supporting structures; Any eye or VisionExamination, or any corrective eyewear required by a Policyholder as a condition of employment; safety eyewear; Services provided asa result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal,state or subdivisions thereof; Plano (non-prescription) lenses and/or contact lenses; Non-prescription sunglasses; Two pair of glasses inlieu of bifocals; Services or materials provided by any other group benefit plan providing vision care; Certain brand name Vision Materi-als in which the manufacturer imposes a no-discount policy; or Services rendered after the date an Insured Person ceases to be coveredunder the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the InsuredPerson are within 31 days from the date of such order. Lost or broken lenses, frames, glasses, or contact lenses will not be replaced ex-cept in the next Benefit Frequency when Vision Materials would next become available.Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Standard/Premium Progressive Lensnot covered - fund as a Bifocal Lens. Standard Progressive Lens covered - fund Premium Progressive as a Standard.Underwritten by Combined Life Insurance Company of New York. CLICNY Form # VN P46900 0801. This is a snapshot of your ben-efits. The Certificate of Insurance is on file with your employer.

MTA HQ has selected EyeMedas your vision wellnessprogram. This plan allows youto improve your healththrough a routine eye exam,while saving youmoney onyour eye care purchases. Theplan is available throughthousands of providerlocations participating on theEyeMedMTA SELECT - PLAN Hnetwork.

To see a list of participatingproviders near you, go towww.enrollwitheyemed.comand chooseMTA SELECT - PLAN H from theprovider locator drop-downbox. You can also call1-866-799-9984.

Enroll today to take advantageof an affordable way to helpensure a lifetime of healthyvision.

With EyeMed Vision Care, you’ll get more than a standard vision benefit. EyeMed’s visionprogram complements your entire health and wellness package by giving you affordable eyecare with the convenience you deserve.

Eye Health Equals Better HealthRegular eye exams do more than just measure your eye sight. They can detect serious eyediseases early, allowing for more proactive treatment. What most people don’t realize is that eyeexaminations can also reveal the early signs of serious illnesses like diabetes, heart disease andhigh blood pressure.

Savings All Year LongEyeMed’s program includes discounts on all your eyewear purchases, even after you’ve usedyour primary benefit. Whether buying additional pairs of glasses or just stocking up on supplieslike cleaning cloths, you never have to pay full price for vision care needs.

Convenience That CountsAs an EyeMed member, you get the convenience your lifestyle demands. You can use yourbenefits at thousands of private practice and retail-affiliated providers across the country, mostwith evening or weekend appointments available. And with the nation’s top optical retail brandsincluded in EyeMed’s network, you’ll find high quality eye care where you live, work and shop.We back this up with a Customer Care Center available seven days a week to respond to yourquestions.

To learn more or to locate a provider near you visit www.eyemedvisioncare.com

Vision Wellness for All

1 2/16/16

DEPENDENT LIFE INSURANCE

Dependent Life Insurance provides coverage for eligible members of your family.

ELIGIBLE EMPLOYEES

Regular full-time employees working at least 30 hours per week.

ELIGIBLE DEPENDENTS

An employee’s spouse and unmarried dependent children are eligible (refer to Exhibit A

for definition of eligible children).

EFFECTIVE DATE OF COVERAGE

For eligible new hires, the effective date of coverage will be the first of the month

following your date of hire of employment, provided the employee is actively at-work on

the date coverage would otherwise become effective, he or she has eligible dependents,

and the employee enrolled in the Plan on a timely basis.

COVERAGE AMOUNT AND COST

Each eligible employee, who has satisfied the criteria as outlined above, will

automatically receive coverage under the OPTION 1 PLAN – fully paid for by the MTA.

In addition, each eligible employee can elect to purchase (via payroll deduction) a higher

level of coverage under either Option 1, 2, 3 or 4.

The monthly cost per Option is as follows:

OPTION COVERAGE AMT. MONTHLY

EMPLOYEE COST

SPOUSE CHILD

1. $5,000 $1,000 $1.28

2* $10,000 $2,000 $2.56

3* $15,000 $3,000 $3.84

4* $20,000 $4,000 $5.12

Example: If you elect Option 3. The MTA is providing Option 1 coverage ($5,000

spouse/$1,000 per child). You are purchasing an additional $15,000.00 in coverage for

your spouse and $3, 000 per child.

CHANGE IN FAMILY STATUS

If there is a change in your family status (for example: marriage, birth or adoption of a

child) you may be able to enroll or increase your coverage by making an election within

31 days after the change. In certain cases, evidence of insurability acceptable to MetLife

will be required to receive coverage under this plan. In this event, the new or increased

coverage will not take effect until the insurance company approves your application.

You must be actively-at-work in order for an increase in coverage to take effect.

2 2/16/16

If there is a change in family status (for example): divorce, dependent child no longer

eligible for coverage and you would like to decrease/cancel coverage, you must contact

Benefits Service Center (BSC), or access the BSC Portal for the appropriate form to

complete. This change will take effect on the first of the month after the month in which

we receive your request.

EMPLOYMENT AND BENEFICIARY DESIGNATION

Each eligible employee must complete an enrollment form, which is included with this

package. Coverage is not automatic.

The employee is automatically the beneficiary under this Plan, unless otherwise indicated

on the Enrollment form.

DEATH BENEFIT

MetLife will pay the amount of an employee’s dependent life insurance coverage when it

receives due proof that the dependent died while insured for this benefit.

DEPENDENT LIFE INSURANCE

DEFINITION OF ELIGIBLE DEPENDENT CHILDREN

Your unmarried children from under 19 years of age are eligible. This includes

your natural and 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 are also eligible.

Your unmarried dependent children who are 19 or over, but under the age 25, are

eligible if they receive more than half of their support from you, and are full-time

students at an accredited secondary or preparatory school, college or other

education institution and are otherwise not eligible for employer group coverage.

They continue to be eligible through the month in which they complete course

requirements for graduation. For children other than your natural children, legally

adopted children or stepchildren, supported by you as described in Paragraph #1

above, must have commenced before the child reached age 19.

If your child reaches age 19 during a school vacation period, coverage will

continue, as long as the child is enrolled in an accredited secondary or preparatory

school or college or other accredited educational institution and plans to resume

classes on a full-time basis at the end of the vacation period.

If your child is granted a medical leave by the school, eligibility for dependent life

insurance coverage will continue for a maximum of one year from the month in

which the student withdraws from class, plus any time before the start of the next

regular semester. You must be able to provide written documentation from the

school and doctor.

3 2/16/16

Your unmarried dependent children who are age 19 or over, but under age of 25,

who need less than a full-time course load to satisfy requirements for graduation

may also be eligible. They must: a) otherwise qualify; and b) have been a full-

time student in the term immediately preceding the semester or trimester in which

course requirements will be completed; and c) be able to provide a statement from

their school or college administrator which verifies the student’s status. They

continue to be eligible through the end of the month in which they complete

course requirements for graduation. Except in unusual circumstances, coverage

will not be extended beyond this semester or trimester unless full-time student

status is resumed.

Your unmarried children age 19 or over who are incapable of supporting

themselves because of mental or physical disability acquired before termination of

your child’s eligibility for coverage are eligible. For example, if your child

becomes disabled on or after their 19th birthday while covered as a full-time

dependent student, the child may qualify to continue coverage as a disabled

dependent.

If you have a child who qualifies for coverage as a disabled dependent when you

enroll, you must provide medical documentation at the time you enroll. If you

anticipate eligibility on this basis, you must file a Disability Form with the carrier.

Contact the BSC several months before your child’s 19th birthday.

If your child is covered as a full-time student between the ages of 19 and 25, and

becomes disabled while in that status, you will need to file a Disability form at the

time the disability occurs.

Note that all benefits described herein are benefits that are currently in effect. These

benefits are all subject to change, including termination thereof, at any time in the sole

discretion of the MTA. The above summary of benefits is for information purposes

only and may be modified at any time. Some benefit programs, such as public

retirement plans, are administered and interpreted outside of the MTA. If information

conflicts with the provisions of any benefit program, the program’s policies control.

1 2/16/16

SUPPLEMENTAL LIFE INSURANCE Supplemental Life Insurance offers extra protection in addition to your basic life insurance benefit. The Supplemental Life Plan is intended to provide added security for your beneficiaries. And, you will have the comfort of knowing that your family will be financially secure.

WHY MORE LIFE INSURANCE? One way to determine how much life insurance you need is to look at your anticipated future needs. Some immediate cash needs your family might face are mortgage or rent, groceries, taxes, education or outstanding charge accounts. Being prepared for the future by obtaining adequate insurance coverage is one way you can guard against an unfortunate situation.

ELIGIBLE EMPLOYEES Regular full-time employees working at least 30 hours per week.

EFFECTIVE DATE OF COVERAGE For those employees who have not yet satisfied the Basic Life Insurance waiting period and for new hires, the effective date of coverage will be the first of the month following your date of employment, provided the employee is actively-at-work on the date coverage would otherwise become effective.

COVERAGE AMOUNT Each eligible employee can elect a supplemental option from one to five times annual base salary. The option you elect will be a multiple of your annual base salary rounded to the next higher $1,000 (if not already a multiple of $1,000).

COVERAGE AMOUNT CONTINUED However, the following restrictions apply:

1. No Medical Statement of Health form will be required for an employee electing to participate in the Plan whose coverage does not exceed 3 times annual base salary or $200,000 (whichever is less) and who enrolls within the 30 days of employment.

2. The enclosed Medical Statement of Health Form must be completed by each

employee electing to participate in the Plan whose coverage exceeds 3 times annual base salary or $200,000 (whichever is less) but does not exceed $750,000 and who enrolls within the open enrollment period.

However, said employee would be automatically covered for 3 times annual base salary or $200,000 (whichever is less). The carrier must review and process (approve or deny) each Medical Statement of Health for any amount in excess of 3 times annual base salary or $200,000 (whichever is less) providing the coverage does not exceed $750,000.

2 2/16/16

3. A Medical Evidence of Insurability Form must be completed for each employee whose coverage exceeds $750,000. However, said employee would be automatically covered for the 3 times annual base salary or $200,000 (whichever is less). The carrier must review and process (either approve or deny) each Medical Evidence of Insurability Form.

COST OF COVERAGE

The monthly cost per $1,000 of Supplemental Life Insurance is based on your current age: Age Bracket Monthly Cost per $1,000 Less than 25 $.050

25 but less than 30 $.060 30 but less than 35 $.080 35 but less than 40 $.090 40 but less than 45 $.113 45 but less than 50 $.179 50 but less than 55 $.291 55 but less than 60 $.489 60 but less than 65 $.752 65 but less than 70 $1.391 70 & Over $2.406

Refer to the attached Calculation Worksheet for examples.

Supplemental Life Insurance premiums are fully paid for by employee

contributions.

ENROLLMENT/WAIVER Each eligible employee must complete an Enrollment/Waiver Form, which is enclosed with this package. Coverage is not automatic.

BENEFICIARY DESIGNATION Each eligible employee who elects to enroll in the Plan must designate his/her beneficiary in Section Three of the Enrollment/Waiver form.

DEATH BENEFIT MetLife Life Insurance will pay the amount of an employee’s supplemental life insurance when it receives due proof that the employee died while insured for this benefit.

Note that all benefits described herein are benefits that are currently in effect. These benefits are all subject to change, including termination thereof, at any time in the sole discretion of the MTA. The above summary of benefits is for information purposes only and may be modified at any time. Some benefit programs, such as public retirement plans, are administered and interpreted outside of the MTA. If information conflicts with the provisions of any benefit program, the program’s policies control.

3 2/16/16

SUPPLEMENTAL LIFE INSURANCE CALCULATION WORKSHEET

EXAMPLE #1

Assume an employee has an annual base salary of $25,100, elects coverage at 3 times annual base salary, and is age 25.

$25,100 x 3 = $75,300 (round-up) = $76,000 in Supplemental Life Insurance Coverage $76,000 x $.06 (age-banded rate) $1,000 (monthly rate is calculated per $1,000 of coverage) = $4.56 Monthly Cost $4.56 (monthly) x 12 months = $54.72 (annually) 26 (pays per year) = $2.10 Bi-weekly (cost per pay) EXAMPLE #2 Assume an employee has an annual base salary of $31,200, elects coverage at 5 times annual base salary and is age 45. ISSUE AT HAND: The employee must complete the Medical Statement of Health Form, since the option elected exceeds 3 times annual base salary. The carrier will need to review and process (approve or deny) the additional 2 times annual base salary coverage. The employee will be automatically eligible for coverage at 3 times annual base salary. $31,200 x 3 = $93,600 Supplemental Life Insurance Coverage Since $93,600 is not a multiple of $1,000, the $93,600 must be rounded to the next higher $1,000. Thus, Supplemental Life Insurance coverage will be $94,000. $94,000 x $.19 (age-banded-rate) $1,000 (monthly rate is calculated per $1,000 of coverage) = $17.86 Monthly Cost If the carrier approves the additional coverage, the monthly cost must be recalculated. EXAMPLE #3 Assume an employee has an annual base salary of $75,000, elects coverage at three times annual base salary, and is age 40. ISSUE AT HAND: The employee must complete the Medical Statement of Health Form, since the elected option exceeds $200,000. The carrier will need to review and process (approve or deny) the additional $25,000 in coverage. The employee will be automatically eligible for the flat $200,000 in coverage. $200,000 x $.12 (age-banded-rate) $1,000 (monthly rate is calculated per $1,000 of coverage) = $24 Monthly Cost If the carrier approves the additional coverage, the monthly cost must be recalculated.

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