Resumen de beneficios - Country Life: Personal Order Entry Portal

Transcripción

Benefits You Can Count On
Prism EPO/Prism PPO/Blue View Vision
Country Life LLC
February 25, 2010
Dear Country Life employee,
This is an important decision and this booklet is designed to help. Basically, it’s a snapshot of the benefits that
come with your Empire coverage. It summarizes what’s available to you, what you get with each benefit and how
your plans work. Of course, you should always refer to your evidence of coverage or medical policy for full plan
details.
We believe your health plan should actually help you manage and improve your health. Since 1935, Empire has
been doing that — helping millions of satisfied members access the health care they need.

There’s a good chance your doctor is part of Empire’s network. To find out, go to empireblue.com and
search the provider directory. We also have one of the largest networks of hospitals and specialists. In fact,
Empire has the most of New York Magazine’s “Best Doctors” for the ninth year in a row.*

You’re covered even when you’re away from home. You can travel outside your area and know you’re
covered through the BlueCard® program.

You get more than basic coverage. You have access to comprehensive benefits that help you take a more
active approach to health and health care.

Empireblue.com can help you find the answers you need — any time, anywhere. Simply go to
empireblue.com for claims questions and to find detailed health benefit information.
This booklet goes into all this — and more. Please take a few minutes to look over the information, and keep this
booklet. It may come in handy.
Registering on empireblue.com is step one.
Once you get your ID card, registering is easy; all you need is your ID card, the Internet and five minutes. Once
you’re registered, you can tap into decision-making tools, health information and many resources. It’s also the
convenient way to order a new ID card, check claims status, find out the cost of many services, learn about
doctors and hospitals, and so much more.

Go to empireblue.com

Enter the site by clicking on Member

Click on Login

Click on Register to use the site

Fill in the required information and follow the prompts
Choosing a health plan can be complicated. Empire helps make it simple. If you expect more from your health
care company, choose Empire.
For any assistance, please call us at 800-662-5193, Monday to Friday, 8:30 a.m. to 5 p.m., Eastern time.
Sincerely,
Mark Wagar
President & CEO
*Based on lists in New York Magazine 6/08/08 issue and searches of competitors’ web sites.
MNYSH6525Y Welcome Ltr
Table of Contents
Page
Plan Overview .............................................................................................................7
Benefit Summaries ..................................................................................................15
Ancillary Benefits ....................................................................................................21
Important Information ............................................................................................45
Plan Overview
MNYSH5967Y (1/09)
SM
Empire Prism EPO
The big buzz these days is that you take charge of your health. That’s why we build our health
plans to provide options, resources and overall support to help you make decisions. But we also
believe in hassle free health care coverage and have built our plans with that in mind.
One, you have flexibility. We offer an extensive network of physicians and hospitals so that you
can choose the right doctor or hospital for you.
Two, as an Empire member, you have access to a lot of online tools. Helping you make your
decisions is important to us, but not nearly as important as helping you make the right
decisions — for you, your health and your budget.
Other ways you take charge with Empire Prism EPO:
}
You pay nothing for in-network covered preventive care. Staying healthy is one of the
best ways to save money. Use a network provider and Empire Prism EPO plan covers your
routine physicals, certain immunizations and certain well-care 100 percent.
}
You don’t need a referral. As long as you see an in-network doctor or specialist for
covered services, you pick who you want to see. You don’t need your doctor or our approval.
}
You’re covered no matter where you go. Access physicians and hospitals, participating
through the BlueCard® PPO program, across the country. And with BlueCard® Worldwide, if
you’re traveling and need urgent care, you have access to covered health care services in
Europe, the Caribbean, Latin America, Asia, the South Pacific, Africa and the Middle East.
}
You get more than just a health plan. You get programs to actually help you manage your
health. MyHealth, 24/7 Nurseline and SpecialOffers are all available through 360° Health®
at empireblue.com. Plus you have 24/7 access to your plan information so you get the help
you need when you need it.
How to Find a Provider
1. Go to empireblue.com
2. Select “Find a Doctor”
3. Select your plan: Empire Prism EPO
4. Select your provider type
5. Select a specialist, if needed
6. Enter your search criteria
7. Click “View Results”
This is a brief overview of your plan’s features. Your evidence of coverage or medical policy
contains the details. Or call us with any questions: 800-662-5193, Monday to Friday, 8:30 a.m.
to 5 p.m., Eastern time.
MNYSH6533Y PrismEPO_Overview
SM
Empire Prism PPO
The big buzz these days is that you take charge of your health. That’s why we build our health
plans to provide options, resources and overall support to help you make decisions. But we also
believe in hassle free health care coverage and have built our plans with that in mind.
One, you have flexibility. You may use any doctor or facility you want — whether in-network or
not — to receive covered services. You’ll typically pay less for services when you use a network
provider. But the decision is still yours.
Two, as an Empire member, you have access to a lot of online tools. Helping you make your
decisions is important to us, but not nearly as important as helping you make the right
decisions — for you, your health and your budget.
Other ways you take charge with Empire Prism PPO:
}
You pay nothing for in-network covered preventive care. Staying healthy is one of the
best ways to save money. Use a network provider and Empire Prism PPO plan covers your
routine physicals, certain immunizations and certain well-care 100 percent.
}
You don’t need a referral. As long as you see an in-network doctor or specialist for
covered services, you pick who you want to see. You don’t need your doctor or our approval.
}
You’re covered no matter where you go. Access physicians and hospitals, participating
through the BlueCard® PPO program, across the country. And with BlueCard® Worldwide, if
you’re traveling and need urgent care, you have access to covered health care services in
Europe, the Caribbean, Latin America, Asia, the South Pacific, Africa and the Middle East.
}
You get more than just a health plan. You get programs to actually help you manage your
health. MyHealth, 24/7 Nurseline and SpecialOffers are all available through 360° Health®
at empireblue.com. Plus you have 24/7 access to your plan information so you get the help
you need when you need it.
How to Find a Provider
2. Select “Find a Doctor”
3. Select your plan: Empire Prism PPO
4. Select your provider type
5. Select a specialist, if needed
contains the details. Or call us with any questions: 800-662-5193, Monday to Friday, 8:30 a.m.
to 5 p.m., Eastern time.
MNYSH6534Y PrismPPO_Overview
Decision support tools help you
make smart choices
If you only do one thing today… make it registering on empireblue.com.
Knowledge is power. The more you know, the easier it is to decide what to do. Once you’re
registered on empireblue.com, you’ll have access to a world of health coverage and benefit
information. Whether you’re healthy or have medical problems, you’ll find tools, resources and
support to help you make smart decisions.
Tap into everything you need to manage your benefits and your health.
Once you’re registered, you have access to all the following.
}
Empire Member Online Services — your personalized benefits site. Many questions you
have can be answered here.
Find a doctor or facility
View coverage and benefit information
Review current and past claims
Request new ID cards
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Lj\k_\j\Zli\d\jjX^\Z\ek\ikfi\Z\`m\e\nj"[il^Xc\ikjXe[k`gjYXj\[fepfli
specific interests
}
Treatment Cost Advisor™ — view estimated costs for specific services, tests, doctor visits
and medications.
}
Anthem Care Comparison — evaluate hospitals based on key quality indicators, and
estimate the costs of specific health care services and procedures.
}
MyHealth Record — build a safe, online health profile so all your important medical
information is in one place, available to you at any time. You start by adding your own
information. Then your record is automatically updated as you use health services and your
claims are paid. Use MyHealth Record to:
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multiple doctors
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important detail or quickly update a new doctor on your medical history
?\cgXmf`[gfk\ek`Xccp[Xe^\iflj[il^èk\iXZk`fej"d\[`Zè\jpflÊi\Xcc\i^`Zkf"fi
duplicative tests and procedures
MNYSH6538Y DecSupTools
13
Decision support tools help you
make smart choices (continued)
}
MyHealth Assessment — helps you pinpoint your personal health risks through a secure
online health analysis. Taking it a step further, you’ll get a personalized report with action
steps designed to help you manage, reduce or eliminate those risks. Plus, MyHealth
Assessment automatically populates MyHealth Record. You can easily follow your progress
as you make recommended lifestyle changes.
}
Staying Healthy Reminders — sent several times a year to encourage scheduling of
important appointments, like a checkup, immunizations or screenings.
}
SpecialOffers — see all the discounts available to you for healthy living products and
services, like fitness club memberships and LASIK.1
}
MyHealth — find tools and information to help you better evaluate and manage your health.
DXeX^\Z_ife`ZXe[XZlk\Zfe[`k`fejk_ifl^_:fe[`k`fe:\ek\ij®
=è[gi\m\ek`feè]fidXk`fe
Dfe`kfiXgi\êXeZpXe[k_\_\Xck_f]Z_`c[i\eX^\jjòXe[pfle^\i
J\XiZ_Xd\[`ZXc[`Zk`feXipn`k_dfi\k_Xe,."'''\eki`\j
8ZZ\jjk_\fecè\Zfddle`k`\jn`k_fm\i*'_\Xck_Xe[n\cce\jjkfg`Zj
Registering is easy.
8ccpfle\\[`jpfli@;ZXi["k_\@ek\ie\kXe[]`m\dèlk\j%
2. Click “Members”
3. Click on Login
4. Click on “Register to use this site”
5. Follow the prompts and fill in the required fields
By the way… It’s for your eyes only!
You can rest easy knowing your personal health information is safeguarded with our strict
privacy and security standards. You can view these standards while online at empireblue.com.
Vendors and offers are subject to change without prior notice. Empire does not endorse and is not responsible for the products, services or information provided by the SpecialOffers
vendors. Arrangements and discounts were negotiated between each vendor and Empire for the benefit of our members.
1
MNYSH6538Y DecSupTools
14
Benefit Summaries
MNYSH5967Y (1/09)
Resumen de beneficios
Prism EPO
Country Life LLC
Dentro de la red1
Sin límite
Hasta los 19 años de edad; los estudiantes de tiempo completo hasta la
edad de 23
El miembro paga
$0
$0
$0
Beneficio
Máximo de por vida
Hijos dependientes (cubiertos hasta finalizar el año calendario)
Atención preventiva6
Atención preventiva para adultos
Examen físico anual
Atención preventiva de niños sanos (hasta los 19 años de edad, incluye vacunas
cubiertas)
Atención preventiva de mujeres sanas
$0
Atención a pacientes externos/en consultorio/domiciliaria7
Visitas en consultorio/domiciliarias
Centro/Sala de emergencias (visita inicial por evento)
El miembro paga
Copago de $25/$40
Copago de $100 (sin copago en caso de admisión dentro de las 24
horas)
Copago de $200 por visita
$0
$0
$0
$0
Copago de $50 por servicio
Cirugía ambulatoria3/de pacientes externos
Pruebas prequirúrgicas, anestesia
Quimioterapia, radioterapia
Atención de maternidad
Pruebas de laboratorio, radiografías6
Resonancia magnética2/angiografía por resonancia magnética2, tomografía axial
computarizada2, tomografía por emisión de positrones2 y cardiología nuclear2
Atención de alergias:
en consultorio
pruebas
tratamiento
Atención quiropráctica5
Atención domiciliaria de la salud (hasta 200 visitas por año calendario)
Terapia de infusión a domicilio
Atención en instalaciones para enfermos terminales (hasta 210 días de por vida,
atención de pacientes internos y externos combinada)
Fisioterapia3
(hasta 60 visitas por año calendario de atención combinada en centros para
pacientes externos, en consultorio o a domicilio)
Otras terapias de rehabilitación a corto plazo, terapia del habla/lenguaje3,
ocupacional3, de la visión
(hasta 60 visitas por año calendario de atención combinada en centros para
pacientes externos, en consultorio o a domicilio)
Rehabilitación cardíaca
Segunda opinión quirúrgica
Diálisis renal
Copago de $25/$40
$0
$0
Copago de $25/$40
$0
$0
$0
Copago de $25/$40
Copago de $25/$40
Copago de $25/$40
Copago de $25/$40
$0
(1) Un proveedor de la red debe brindar toda la atención, excepto en casos de emergencia. No existe una opción fuera de la red para este producto.
(2) Para recibir servicios de un proveedor de la red de Empire, el proveedor debe otorgarle una certificación previa; de lo contrario, los servicios pueden ser rechazados. Los proveedores de la red de Empire sólo
pueden cobrar copagos o coaseguros a los miembros por servicios cubiertos. Fuera del área de la red de Empire, usted debe obtener certificación previa del programa de administración médica de Empire
para servicios que no son de emergencia prestados por proveedores dentro de la red de BlueCard® PPO (excepto para resonancias magnéticas, angiografías por resonancia magnética, tomografías por
emisión de positrones, tomografía axial computarizada y cardiología nuclear, que no requieren certificación previa para servicios prestados por proveedores dentro de la red de BlueCard® PPO que se
encuentren fuera del área de la red de Empire).
(3) Usted es responsable de obtener la certificación previa del programa de administración médica de Empire para estos servicios. Su proveedor puede comunicarse en representación suya, pero usted será
responsable de las multas que correspondieren por no obtener certificación previa. En el caso de la cirugía ambulatoria, se requiere certificación previa para cirugía reconstructiva, trasplantes a pacientes
externos y procedimientos oftalmológicos o relacionados con los ojos. La certificación previa también es necesaria para la cirugía cosmética ofrecida, que se excluye como beneficio a menos que sea
médicamente necesaria.
(4) Usted es responsable de obtener la certificación previa del programa de administración de la atención de la salud del comportamiento de Empire. Su proveedor puede comunicarse en representación suya,
pero usted será responsable de las multas que correspondieren por no obtener certificación previa.
Los servicios son proporcionados por Empire HealthChoice HMO, Inc. y/o Empire HealthChoice Assurance, Inc.; licenciatarios de Blue Cross and Blue Shield Association, una asociación de los planes
independientes de Blue Cross and Blue Shield.
17
Beneficio
Atención a pacientes internos3
Servicios hospitalarios para pacientes internos
(tantos días como sea médicamente necesario; comida y estadía
en habitación semiprivada)
Cirugía, asistente quirúrgico, anestesia
Fisioterapia, medicina física o rehabilitación
(hasta 30 días como paciente interno por año calendario)
Centro de enfermería especializada
(hasta 60 días por año calendario)
Salud mental4
Visitas como paciente externo en consultorio o centro
Atención a pacientes internos
Abuso de alcohol/sustancias4
Visitas como paciente externo
Desintoxicación como paciente interno
Rehabilitación de pacientes internos (hasta 30 días por año
calendario)
Otros
Suministros médicos
Equipo médico duradero3
Prótesis y ortótica3
Ambulancia (ambulancia aérea)
Reembolso de la membresía de gimnasio
Medicamentos de venta bajo receta8
Programa de venta minorista: se requiere un copago por un
suministro de hasta 30 días
Programa de venta por correo9: se requieren sólo dos copagos
por un suministro de 90 días
Dentro de la red1
El miembro paga
$500/$1250 por admisión/máximo por año calendario por contrato
$0
Copago de $100/$250 por admisión/máximo por año calendario por contrato
Copago de $40
Copago de $40
$0
Copago de $0 (beneficio máx. de $2,000/año cal.)
$0
El miembro recibe un reembolso de $600 por año
Suma deducible de $100 por persona, por año calendario
Opción 2
Copago de $10 para medicamentos genéricos
Copago de $35 para medicamentos de marca
Copago de $70 para medicamentos que no pertenecen a la lista
Incluye anticonceptivos (minorista o por correo)
Suma deducible de $0
El programa de venta por correo tiene los mismos copagos que el programa de venta
minorista antes mencionado.
(5) Los proveedores de la red de Empire deben obtener autorización de necesidad clínica/médica para servicios dentro de la red; de lo contrario, éstos pueden ser rechazados. Los proveedores de la red de
Empire sólo pueden cobrar copagos y coaseguros a los miembros por servicios cubiertos. La autorización no es necesaria para los servicios recibidos de proveedores dentro de la red de BlueCard® PPO
fuera del área de la red de Empire.
(6) Los siguientes beneficios, si se prestaron dentro de la red para atención preventiva, no están sujetos al copago: mamografías de detección, pruebas de detección de cáncer cervical, pruebas de detección
de cáncer de colon y recto, pruebas de detección de cáncer de próstata, pruebas de detección de hipercolesterolemia, pruebas de detección de diabetes para mujeres embarazadas, pruebas de densidad
ósea, exámenes físicos anuales, y hasta dos exámenes ginecológicos y obstétricos al año.
(7) Los siguientes profesionales reciben el copago más bajo (primario) por los servicios brindados en el consultorio: PCP del paciente, obstetras, ginecólogos, enfermeros obstetra certificados, quiroprácticos, y
terapeutas (fisioterapia, terapia ocupacional, del habla y de la visión). El copago más alto (especialista) corresponde para todos los demás especialistas cuando se requiere copago, y para los servicios de
fisioterapia y terapia del habla, del lenguaje, ocupacional, de la visión y cardíaca recibidos en un centro para pacientes externos.
(8) Los planes de medicamentos de venta bajo receta detallados, excepto las opciones 3 y 5, cumplen con la norma de los Centros de Servicios de Medicare y Medicaid (CMS, Centers for Medicare & Medicaid
Services) para la cobertura acreditable según la Ley de Modernización de Medicare de 2003.
(9) Para recibir un suministro de 90 días de medicamentos de venta bajo receta a través del programa de venta por correo de Empire, debe indicarse específicamente en la receta que se solicita un suministro
de 90 días.
NOTA: El presente es solamente un resumen de beneficios y se encuentra sujeto a los términos, a las condiciones, a las limitaciones y a las exclusiones establecidas en el contrato. Si no se cumplen los
requisitos del programa de administración médica o del programa de atención de la salud del comportamiento de Empire, los beneficios pueden sufrir reducciones.
Prism EPO Rev. octubre 09
Preparado el 2/24/10 be
18
Prism PPO
Country Life LLC
Beneficio
Suma deducible
Coaseguro
Límite del coaseguro
Máximo de por vida
Hijos dependientes
Atención preventiva9
Atención preventiva para adultos
Examen físico anual
Atención preventiva de niños sanos
(hasta los 19 años de edad, incluye vacunas
cubiertas)
Atención preventiva de mujeres sanas
Atención a pacientes externos/en
consultorio/domiciliaria10
Visitas en consultorio/domiciliarias
Centro/sala de emergencias
(visita inicial por evento)
Cirugía ambulatoria4/cirugía para pacientes externos
Pruebas prequirúrgicas, anestesia
Quimioterapia, radioterapia
Atención de maternidad
Pruebas de laboratorio, radiografías9
Resonancia magnética5/angiografía por resonancia
magnética5, tomografía axial computarizada6,
tomografía por emisión de positrones6 y cardiología
nuclear6
Atención de alergias:
visita al consultorio
pruebas
tratamiento
Atención quiropráctica8
Atención domiciliaria de la salud (hasta 200 visitas por
año calendario)
Terapia de infusión a domicilio
Atención en instalaciones para enfermos terminales
(hasta 210 días de por vida, atención de pacientes
internos y externos combinada)
Fisioterapia4
(hasta 60 visitas por año calendario de atención
combinada en centros para pacientes externos, en
consultorio o a domicilio)
Otras terapias de rehabilitación a corto plazo:
Del habla/del lenguaje4, ocupacional4, de la visión
(hasta 60 visitas por año calendario de atención
combinada en centros para pacientes externos, en
consultorio o a domicilio)
Dentro de la red1
N/A
N/A
N/A
Sin límite
Hasta los 19 años de edad; los estudiantes de
tiempo completo hasta la edad de 23
Los miembros pagan dentro de la red
Copago de $0
Copago de $0
Copago de $0
Fuera de la red2,3
$2,000/$5,000
30%
$25,000/$62,500 / (máx. de bolsillo de $9,500/$23,750)
Sin límite
Hasta los 19 años de edad; los estudiantes de tiempo completo hasta la
hasta la edad de 23
Los miembros pagan fuera de la red
Suma deducible y coaseguro
Copago de $0
Copago de $25/ $40
Copago de $100
(sin copago en caso de admisión dentro de las
24 horas)
Copago de $200
$0
$0
$0
$0
Copago de $50 por servicio
Copago de $100
(sin copago en caso de admisión dentro de las 24 horas)
Copago de $25/ $40
$0
$0
Copago de $25/ $40
$0
Coaseguro (sin suma deducible)
$0
$0
Cubierto únicamente dentro de la red
Copago de $25/ $40
Copago de $25/ $40
(1) Un proveedor de la red brinda la atención.
(2) Los servicios fuera de la red (excepto los de salud mental y por abuso de alcohol y sustancias) son aquellos recibidos de un proveedor que no participa en la red PPO de Empire, o con otro plan de Blue Cross and Blue Shield a través del programa BlueCard® PPO.
(Esto no corresponde a los beneficios de emergencia). Consulte el punto (7) para tener información sobre los servicios de salud mental, y por abuso de alcohol y sustancias.
(3) Proveedores fuera de la red (O-O-N): aquellos que no participan en la red PPO de Empire o que operan con otro plan de Blue Cross and Blue Shield a través del programa BlueCard® PPO. Los proveedores fuera de la red que no trabajan con Empire u otro plan de
Blue Cross and Blue Shield pueden facturar el saldo sobre la suma permitida de Empire.
(4) Usted es responsable de obtener la certificación previa del programa de administración médica de Empire para estos servicios brindados dentro del área y fuera de ésta, y dentro de la red y fuera de ella. Su proveedor puede comunicarse en representación suya,
pero usted será responsable de las multas que correspondieren por no obtener certificación previa. En el caso de la cirugía ambulatoria, se requiere certificación previa para cirugía reconstructiva, trasplantes a pacientes externos y procedimientos oftalmológicos o
relacionados con los ojos. La certificación previa también es necesaria para la cirugía cosmética, que se excluye como beneficio a menos que sea médicamente necesaria.
Las referencias continúan en la página siguiente.
19
Beneficio
Rehabilitación cardíaca
Segunda opinión quirúrgica
Diálisis renal
Atención a pacientes internos4
Servicios hospitalarios para pacientes internos
(tantos días como sea médicamente necesario; comida y
estadía en habitación semiprivada)
Cirugía, asistente quirúrgico, anestesia
Fisioterapia, medicina física o rehabilitación
(hasta 30 días como paciente interno por año calendario)
Centro de enfermería especializada (hasta 60 días por año
calendario)
Atención de la salud mental7
Visitas como paciente externo en consultorio o centro
Atención a pacientes internos8 (tantos días como sea
médicamente necesario; comida y estadía en habitación
semiprivada)
Alcohol/Abuso de sustancias7
Visitas como paciente externo
Desintoxicación como paciente interno (tantos días como
sea médicamente necesario; comida y estadía en
habitación semiprivada)
Rehabilitación de pacientes internos(hasta 30 días por año
calendario)
Otros
Suministros médicos
Equipo médico duradero6
Prótesis y ortótica6
Ambulancia (ambulancia aérea)
Reembolso de la membresía de gimnasio
Medicamentos de venta bajo receta11
Programa de venta minorista: se requiere un copago por
un suministro de hasta 30 días
Programa de venta por correo12: se requieren sólo
dos copagos por un suministro de 90 días
Dentro de la red1
Copago de $25/ $40
Copago de $25/ $40
$0
$500/$1250 por admisión/máximo por año
calendario por contrato
Fuera de la red2,3
$0
Copago de $100/$250 por admisión/máximo por
año calendario por contrato
Copago de $40
Copago de $40
$0
$0
El miembro recibe un reembolso de $600 por año
N/A
Suma deducible de $100 por persona, por año
calendario
Opción 2
Copago de $10 para medicamentos genéricos
Copago de $35 para medicamentos de marca
Copago de $70 para medicamentos que no
pertenecen a la lista
Incluye anticonceptivos (minorista o por correo)
Suma deducible de $0
El programa de venta por correo tiene los mismos
copagos que el programa de venta minorista
antes mencionado.
(5) Para recibir servicios de un proveedor de PPO de Empire, el proveedor debe otorgarle una certificación previa para servicios dentro de la red; los proveedores de PPO de Empire sólo pueden cobrar copagos o coaseguros a los miembros por servicios cubiertos.
Fuera del área de la red de Empire, usted debe obtener una certificación previa del programa de administración médica de Empire para servicios prestados por proveedores dentro de la red de BlueCard® PPO. Usted es responsable de obtener la certificación
previa del programa de administración médica de Empire para los servicios brindados fuera de la red, y dentro del área o fuera de ella. Su proveedor puede comunicarse en representación suya, pero usted será responsable de las multas que correspondieren por
no obtener certificación previa.
(6) Los proveedores de la red de Empire deben otorgarle una certificación previa para los servicios de la red; los proveedores de la red de Empire sólo pueden cobrar a los miembros el copago por los servicios cubiertos. La certificación previa no es necesaria para
los servicios fuera de la red, ni para los servicios brindados por proveedores dentro de la red, pero fuera del área de BlueCard® PPO.
(7) Usted es responsable de obtener la certificación previa del administrador de la atención de salud para estos servicios. Su proveedor puede comunicarse en representación suya, pero usted será responsable de las multas que correspondieren por no obtener
certificación previa.
(8) Los proveedores de la red de Empire deben obtener autorización de necesidad clínica/médica para servicios dentro de la red; los proveedores de la red de Empire sólo pueden cobrar a los miembros los copagos por servicios cubiertos dentro de la red. La
autorización no es necesaria para los servicios fuera de la red o para los servicios recibidos de proveedores dentro de la red de BlueCard® PPO, pero fuera del área de la red de Empire.
(9) Los siguientes beneficios, si se prestaron dentro de la red para atención preventiva, no están sujetos al copago: mamografías de detección, pruebas de detección de cáncer cervical, pruebas de detección de cáncer de colon y recto, pruebas de detección de
cáncer de próstata, pruebas de detección de hipercolesterolemia, pruebas de detección de diabetes para mujeres embarazadas, pruebas de densidad ósea, exámenes físicos anuales, y hasta dos exámenes ginecológicos y obstétricos al año.
(10) Los siguientes profesionales reciben el copago más bajo (primario) por los servicios brindados en el consultorio: PCP del paciente, obstetras, ginecólogos, enfermeros obstetra certificados, quiroprácticos, y terapeutas (fisioterapia, terapia ocupacional, del habla y
de la visión). El copago más alto (especialista) corresponde para todos los demás especialistas cuando se requiere copago, y para los servicios de fisioterapia y terapia del habla, del lenguaje, ocupacional, de la visión y cardíaca recibidos en un centro para
pacientes externos.
(11) Los planes de medicamentos de venta bajo receta detallados, excepto las opciones 3 y 5, cumplen con la norma de los Centros de Servicios de Medicare y Medicaid (CMS, Centers for Medicare & Medicaid Services) para la cobertura acreditable según la Ley
de Modernización de Medicare de 2003.
(12) Para recibir un suministro de 90 días de medicamentos de venta bajo receta a través del programa de venta por correo de Empire, debe indicarse específicamente en la receta que se solicita un suministro de 90 días.
NOTA: El presente es solamente un resumen de beneficios y se encuentra sujeto a las condiciones, las limitaciones, las exclusiones y los términos establecidos en el contrato. Si no se cumplen los requisitos del programa de
administración médica o del programa de atención de la salud del comportamiento de Empire, los beneficios pueden sufrir reducciones.
Empire Prism PPO Rev. agosto 09
Preparado el 2/24/10 be
20
Ancillary Benefits
MNYSH5967Y (1/09)
National Chain Pharmacies*
The following is a list of the national chain pharmacies that
participate in our national retail pharmacy network. To verify if your
pharmacy is in the national network, please visit empireblue.com
or call the customer service number listed on your ID card. Check
with your local independent pharmacy to ensure that it is a member
or partipcates in this network, managed by NextRx Services, Inc. or
NextRx, LLC. Please present your member ID card when purchasing
your prescription.
A & P U.S.
A W G Network
AADP
Accesshealth
Acme Pharmacy
Albertsons, LLC
Allina Community
Pharmacies
Allscripts Healthcare
Solutions, Inc.
American Drug Stores,
Inc.
American Pharmaceutical
Services
American Pharmacy
Cooperative, Inc.
Amerita, Inc.
Appalachian Reg. Health
Care
Arbor Drugs Inc
Arrow Prescription Center
Astrup Drug, Inc.
Atlas Drugs
Aurora Pharmacy, Inc.
Balls Four B Corporation
Bartell Drugs
Bi-Lo Pharmacy, LLC
Bi-Mart Drugs
Big A Drugstores, Inc.
Bioscrip Pharmacy
Bioscrip Stores
(Any Willing Provider)
Brooks Maxi Drug
Brookshire Brothers, Ltd.
Brookshire Grocery
Company
Brown and Cole, Inc.
Bruno’s Food and
Pharmacy
Buehler Pharmacies
Buehlers Buy Low
Pharmacy
Busch’s, Inc
Care Drug Centers, Inc.
Caremark Pharmacy
Services
Carle Rx Express
Carrs Quality Center
CBC Professional
Pharmacy, Inc.
Cincinnati Group Health
Associates Pharmacies
City Market Pharmacy
Coborns Incorporated
Community Pharmacies
Costco Pharmacies
CVS Pharmacy
CVS Procare Pharmacy,
Inc.
CVS/Procare Pharmacy
Dierberg’s
Dillon Pharmacy
Discount Drug Mart
Docs Drugs, Ltd
Dominicks Pharmacy
Drug Fair
Drug World
Duane Reade
Duluth Clinic Pharmacies
Eaton Apothecary
Eckerd Drug
Epic Pharmacy Network
Fagen Pharmacy
Fairview Family
Services, LLC
Family Care Network
Family Fare Pharmacy
Family Pharmacy, Inc.
Familycare Plus
Familymeds, Inc.
Farm Fresh Pharmacy
Food City-K-Va-T Food
Stores
Food Lion, LLC
Foodarama Supermarkets
Fred Meyer Pharmacy
Freds Pharmacy
Fruth PharmacY
Fry’s Pharmacy
Gerimed
Giant Eagle Pharmacy
Giant of Maryland
Pharmacies
Giant Pharmacy
Good Neighbor Pharmacy
Provider Network
Grand Union Markets LLC
Gristedes Sloans, Inc.
H E B Pharmacy
H.I.P. Pharmacy Service
Haggen Foods
Hannaford Brothers
Harmons Pharmacy
Harps Food Stores, Inc.
Harris Teeter Pharmacy
Hartig Drug Store
Harvard Vanguard
Medical Associates
Harvest Foods Pharmacy
Health Partners
Healthmart Pharmacies/
AccessHealth
Heartland Pharmacy
Henry Ford Health
System
Hi-School Pharmacy
Homeland Stores, Inc.
Horton and Converse
Pharmacy
Hy-Vee Pharmacy
IHC Pharmacy Services
IHS Infusion Services
Ingles Markets
Innovatix
Inserra Supermarkets/
Shoprite
Instymeds
JH Harvey Co, LLC
JSA Healthcare
Corporation
K Mart Pharmacy
Kash N’ Karry Food Stores
Inc.
Kelsey-Seybold
Pharmacies
Kerr Drug
Keystone Pharmacy
Kindred Pharmacy
King Soopers Pharmacy
Kinney Drugs
Klingensmiths Drug Store
Knight Drugs
Kohll’s Pharmacy &
Homecare
Kopp Drug
Kroger Pharmacy
Lallie Supermarkets
Leader Drugstores
Lincare, Inc.
Lins Supermarkets, Inc
Longs Pharmacies
Louis and Clark Drug
M K Stores, Inc.
Major Value Pharmacy
Network
Managed Pharmacy Care
* Subject to number of store locations, geography of store locations and prescription volume.
23
Marc’s Pharmacy
Marsh Drugs LLC
Marshfield Clinic
Pharmacy
Martins Super Markets,
Inc.
Maxor Pharmacies
May’s Drug Store
Med-Fast Pharmacy
Med-X Drug
Medical College VA
Hospital/VA Comm Univ.
Medicap Pharmacies
Medicine Centers of
Atlanta
Medicine Shoppe
International
Mediserv, Inc.
Meijer Pharmacy
Methodist Medical Group
MHA LTC Network, Inc.
Miller Pharmacy
Nash Finch Company
Navarro Discount
Pharmacy
Neighborcare Omnicare
Infusion
Neighborcare Pharmacy
Neighborcare Pharmacy
of Virginia
Northwest Health
Ventures, Inc.
Oakwood Pharmacy
Oklahoma Area Indian
Health Services
Omnicare / NCS
Healthcare
Pacific Medical Clinics
Pamida Pharmacy
Park Nicollet Pharmacy
Pathmark Pharmacy
Patient First
Pavillion Plaza
Pharmacy, Inc.
Penn Traffic Company
Peoples Pharmacy
Performance Plus
Network
Perlmart/Shoprite
Pharma Card Management
Services, Inc
Pharmacy Express
Serivces, Inc.
Pharmacy Operations, Inc.
Pharmerica-Northeast
Region
Pharmerica-Southeast
Region #1
Pharmerica-Southeast
Region #3
Pharmerica-West
Pharmerica/Mid-Atlantic
Region
Phoenix Area Indian
Health Services
POC Management Group,
LLC
Polks Discount Drugs
PPOK/Rx Select Pharmacy
Network
Price Chopper
Supermarkets
Price Cutter Pharmacy
Price Wise Pharmacy
Publix Pharmacy
QOL Meds/Specialized
Pharmaceuticals, Inc.
Quality Food Centers, Inc.
Quality Markets Pharmacy
Quick Chek Pharmacy
Dept
Raleys Drug Center
Ralph’s Grocery Pharmacy
Randalls Food & Drug, Inc.
Recept Pharmacies
Revco Discount Drug
Rinderers Drug Store
Rite Aid Pharmacy
Ronetco Stores/Shoprite
Rushford Drug, Co.
Rx Pride, LLC
RxD Pharmacy
Safescript Pharmacies,
Inc.
Safeway Pharmacy
Sav-Mor Drug Stores
Save Mart Pharmacy
Schnucks Pharmacy
Scolaris Food and Drug
Pharmacy
Sedanos Pharmacy
Discount
Sedell’s Pharmacy
Serv-U Pharmacies
Sharp Rees-Stealy
Pharmacy
Shaw’s Supermarkets
Shelly’s Pharmacy
Shopko Pharmacy
Shoprite Financial
Services
Shoprite Pharmacy
Shoprite Rx
Shoprite, Inc.
Smiths Pharmacy
Snyder Drug
Southern Family Markets,
LLC
Spartan Stores/The
Pharm
St. John Pharmacies
St. Joseph Mercy
Pharmacy
Standard Drug Company
Stop & Shop Pharmacy
Super D Drugs
Supervalu Pharmacies,
Inc.
Target Pharmacy
The Penn Traffic Co.
Third Party Station
Thrifty White Drug
TKP, Inc.
Tops Markets, LLC
Tops Pharmacy Services,
Inc.
Trinet Pharmacy
UCSD Medical Center
UIPC
Ukrops Pharmacy
United Drugs
United Drugs (Alaska)
United Supermarkets, Ltd
Unity Retail Pharmacies/
St. John Mercy
University Medical Center
of Southern Nevada
University of Missouri
Hospital and Clinic
University of Utah
University of Wisconsin
Upni-United Pharmacist
Network, Inc.
USA Drug and Beauty
Market
USA/Super D
Franchising, Inc.
Value Drugs
Village Supermarkets/
Shoprite
VONS Companies
Wal-Mart Pharmacy
Walgreens Drug Store
Wayne Drug Company
24
Wayne Oakland Pharmacy
Management
Wegman Food Market
Pharmacy
Weis Pharmacies
Winn Dixie Pharmacy
This list is subject to change
without prior notice.
List current as of
April 2009.
For more information
or to verify if your local
independent pharmacy is
a participating provider,
visit empireblue.com.
Services provided by Empire HealthChoice
HMO, Inc. and/or Empire HealthChoice
Assurance, Inc., licensees of the BlueCross
and BlueShield Association, an association
of independent BlueCross and BlueShield
plans. The BlueCross and BlueShield names
and symbols are registered marks of the
BlueCross and BlueShield Association.
MNYSH6542YLG RxRetailList EBCBS 7/09
Prescription Program
Drug List/Formulary — To be used by members who have a formulary drug plan.
Empire BlueCross BlueShield prescription drug benefits include medications available on the Empire
Drug List/Formulary. Our prescription drug benefits can offer potential savings when your physician
prescribes medications on the drug list/formulary.
Questions and Answers
Q. What is a Drug List/Formulary?
A. The Empire Drug List/Formulary is a list of FDA-approved brand-name and generic medications that
have been reviewed and recommended for their quality and effectiveness by the National Pharmacy
and Therapeutics (P&T) Committee. The P&T Committee is an independent group of practicing doctors
and pharmacists responsible for the research and decisions surrounding our drug list. This group meets
regularly to review new and existing drugs and choose the top medications for our drug list — based on
their safety, effectiveness and value.
Drugs on the Empire Drug List/Formulary are grouped by ‘tiers.’ A number of factors are considered
when classifying drugs into tiers, including, but not limited to: the absolute cost of the drug; the cost
of the drug relative to other drugs in the same therapeutic class; the availability of over-the-counter
alternatives; and other clinical and cost-effectiveness factors.
Because the medications on the drug list/formulary are subject to periodic review, please ask your
physician about the most current drug list additions and deletions or visit empireblue.com.
Brand-name: A brand-name drug is usually available from only one manufacturer and may have patent protection.
Generic: A generic drug is required by the FDA to have the same active ingredients as its brand-name
counterpart, but is normally only available after the patent protection expires on a brand-name drug.
Although it may look different, a generic drug works the same as its brand-name counterpart. You can save
money by using generic medications.
Q. What if my physician or I choose a brand-name drug when a generic equivalent is available?
A. In most cases, you would be responsible for the appropriate tier copay. This copay may include an
additional charge that represents the cost difference between the brand-name medication and the
generic equivalent.
Q. What are ‘clinically equivalent’ medications? How does this affect my drug coverage?
A. The P&T Committee reviews the most current research available to determine if multiple drugs used to treat a
disease/condition produce the same clinical effect. When this is the case, the committee may recommend that
we cover only the lower cost drug(s) as part of our effort to help reduce the overall cost of care. This means your
specific prescription plan may not cover some drugs in classes with ‘clinically equivalent’ alternatives.
Q. What if my medication is not on the drug list/formulary?
A. An open drug list allows members and their physicians to choose from a wide variety of prescription
medications. Please talk with your doctor about prescribing a Tier 1 or Tier 2 medication. If a Tier 3 medication
is selected, you will be responsible for the applicable Tier 3 copayment.
You or your physician may submit a request to add a drug to the drug list/formulary either in writing or on
our website. Requests are taken into consideration by the P&T Committee during the drug list/formulary
review process.
Inclusion of a medication on the drug list/formulary is not a guarantee of coverage. Some drugs, such as
those used for cosmetic purposes, may be excluded from your benefits. Please refer to your Certificate or
Evidence of Coverage for coverage limitations and exclusions.
MNYFM6596YLG RxFormulary EBCBS 01/10
25
Drugs are listed alphabetically by brand name
A
A/T/S Topical Solution
(erythromycin)*
Abilify
Accu-Check product line
Accutane (isotretinoin)*
Aceon (perindopril)*
Aci-Jel Jelly (acetic acid
vaginal)*
Actigall (ursodiol)*
Activella 0.1-0.5
Activella 1.0-0.5 (estradiol/
norethindrone)*
Actonel
ActoPlus Met
Actos
Acular, LS (ketorolac)
Akne-Mycin
Adalat CC (nifedipine ER)*
Adderall (amphetamine/
dextroamphetamine)*
Adderall XR (amphetamine/
dextroamphetamine^#)
Advair
Advicor
Aerobid
Aerobid M
Agenerase
Akne-Mycin
Albalon (naphazoline)*
Aldactazide
(spironolactone/HCTZ)*
Aldactone (spironolactone)*
Aldara
Aldomet (methyldopa)*
Aldoril (methyldopa/HCTZ)*
Alesse (aviane)*
Alkeran
Allegra (fexofenadine)*
Allegra D^ (fexofenadine/
PSE 12hr)*
Alphagan (brimonidine)*
Alphagan P
Altace (ramipril)*
Altabax
Alupent (metaproterenol)*
Amaryl (glimepiride)*
Ambien (zolpidem)*
Amicar (aminocaproic acid)*
amitriptyline
amitriptyline/perphenazine
Amoxil (amoxicillin)*
Anafranil (clomipramine)*
Analpram HC lotion
Anaprox, DS
(naproxen sodium, DS)*
Androderm
Androgel
Anexsia (hydrocodone/APAP)*
Ansaid (flurbiprofen)*
Antabuse
Antivert (meclizine)*
Anturane (sulfinpyrazone)*
Anusol HC 25mg Suppositories
(hydrocortisone)*
Apidra
Apresazide (hydralazine/
HCTZ)*
Apresoline (hydralazine)*
apri
Arava (leflunomide)*
Aricept
Arimidex
Aristocort Topical
(triamcinolone-acetonide)*
Armour Thyroid
Aromasin
Artane (trihexyphenidyl)*
Asacol, HD
Asendin (amoxapine)*
Asmanex
Astelin
Astepro
Atarax (hydroxyzine HCL)*
Ativan (lorazepam)*
Atrovent HFA
Atrovent
(ipatropiumbromide)*
Augmentin (amoxicillin/
clavulanic acid)*
Auralgan (antipyrine/
benzocaine)*
Avandamet
Avandaryl
Avandia
Avinza
Avodart
Axid (nizatidine)*
Aygestin (norethindrone)*
Azasan
AzaSite
Azopt
Azulfidine, Entabs
(sulfasalazine, EC)*
B
Bactrim DS (Sulfamethoxazole/
trimethoprim, DS)*
Bactroban
Benadryl (diphenhydramine
50mg)*
Bentyl (dicyclomine)*
Benzac, AC, W (benzoyl
peroxide)*
Benzaclin (benxoyl peroxide/
clindamycin)*
Benzagel, Wash (benzoyl
peroxide)*
Benzamycin (benzoyl peroxide/
erythromycin)*
Betagan (levobunolol)*
Betimol
Betoptic S
Biaxin, XL (clarithromycin, er)*
Bicitra (sodium citrate &
citric acid)*
BiDil
Bleph-10 (sulfacetamidesodium solution)*
Blephamide
Brethine (terbutaline)*
Bumex (bumetanide)*
Buspar (buspirone)*
Byetta
C
Cafergot
Casodex (bicalutamide)*
Catapres, TTS (clonidine)*
Colazol
colchicine
Colyte (polyethylene glycolelectrolyte solution)*
CombiPatch
Combipres (clonidine/
chlorthalidone)*
Combivent
Combivir
Compazine Supp 25mg
(prochlorperazine supp
25mg)*
Compazine Tab
(prochlorperazine)*
Comtan
Concerta
Condylox Solution (podofilox
solution)*
Cordarone (amiodarone)*
Coreg (carvedilol)*
Coreg CR
Corgard (nadolol)*
Cortef (hydrocortisone)*
Cortenema (hydrocortisone
enema)*
Cortifoam
Cortisporin Ophth (bacitracin
- polymyxin/neomycin- hc
opth oint)*
Cortisporin Otic (neomycin/
polymixin/hydrocortisone)*
Cosopt (dorzolamide/timolol)*
Coumadin (warfarin)
Cozaar
Creon
Crestor
Crixivan
Crolom (cromolyn sodium)*
Cuprimine
Cyclocort (amcinonide)*
Cyclogyl (cyclopentolate)*
Cylert (pemoline)*
Cymbalta
cyproheptadine
Cytomel (liothyronine)*
Cytotec (misoprostol)*
Cytovene (ganciclovir)*
Cytoxan (cyclophosphamide)*
Cytra-2, Cytra-3
Cytra-K
D
Dalmane (flurazepam)*
Danocrine (danazol)*
Dantrium (dantrolene)*
Dapsone
Daraprim
Darvocet-N (propoxyphene/APAP)*
Darvon Compound
(propoxyphene/aspirin/
caffeine)*
Daypro (oxaprozin)*
DDAVP (desmopressin
acetate)*
Decadron (dexamethasone)*
Deconamine S.R.
(chlorpheniramine/
pseudoephedrine)*
Demadex (torsemide)*
Demerol (meperidine)*
Demulen 28 day (ethinyl
estradiol/ethynodiol
diacetate-zovia)*
Depakene (valproic acid)*
Depakote (divalproex)
Depakote ER
Depo-Provera 150mg
medroxyprogesterone)*
Derma-Smoothe/FS
Desogen (apri)*
Desowen Cream (desonide)*
Desquam, E, X (benzoyl
peroxide)*
Desyrel (trazodone)*
Detrol, LA
Dexedrine, CR
(dextroamphetamine)*
Dextrostat
(dextroamphetamine)*
Diabeta (glyburide)*
Diamox (acetazolamide)*
Diastat
Dibenzyline
Differin
Diflucan (fluconazole)*
diflunisal
Dilacor XR (diltiazem CR)*
Dilantin (phenytoin)
Dilaudid (hydromorphone)*
diltia XT
Diovan
Diovan HCT
Dipentum
Diprolene Ointment (betamet
diprop/prop gyl)*
Diprosone (betamethasone
dipropionate)*
Disalcid (salsalate)*
Ditropan (oxybutynin)*
Dolophine (methadone)*
Domeboro (acetic acid/
aluminum acetate)*
Donnatal (belladonna/
phenobarbital)*
Dostinex (cabergoline)*
Dovonex cream
Dovonex soln (calcipotriene)*
Duac CS
Duetact
Duragesic (fentanyl)*
Duratuss G (guaifenesin SR)*
Duricef Caps/Tabs (cefadroxil)*
Dyazide (triamterene/HCTZ)*
Dynacin (minocycline)*
Dynapen (dicloxacillin)*
E
E.E.S. (erythromycin
ethylsuccinate)*
EC-Naprosyn (naproxen EC)*
Econopred Plus 1% Eye Drops
(prednisolone)*
26
Effexor (velafaxine)*
Effexor XR
Efudex (fluorouracil)*
Eldepryl (selegiline)*
Elidel
Elimite (permethrin)*
Elixophyllin (theophylline
syrup)*
Elocon (mometasone)*
Emcyt
Empirin w/Cod (asa/codeine)*
Emtriva
Endal HD (phenyleph hcl/
hydrocod bit/cp)*
Entex PSE (guaifenesin/
pseudoephedrine)*
Entocort EC
Epifrin (epinephrine HCl)*
Epipen, JR
Epivir
Eryc (erythromycin base)*
Erycette 2% Pledgets
(erythromycin)*
Eryderm 2% Topical Solution
(erythromycin)*
Erymax 2% Topical Solution
(erythromycin)*
EryPed 200 Susp (erythromycin
ethylsuccinate)*
Esgic (acetaminophen/
caffeine/butalb)*
Eskalith, CR (lithium)*
Estrace (estradiol)*
Estraderm
Estring
Ethmozine
Euflexxa
Eulexin (flutamide)*
Evamist
Evista
Evoxac
Exelon
Exforge, HCT
F
Famvir (famciclovir)*
Fansidar
Fast Take Product Line
FazoClo ODT
Felbatol
Feldene (piroxicam)*
Femara
Fem HRT
Fibricor (fenofibric acid)*
Finacea
Fioricet (APAP/caffeine/
butalbital)*
Fiorinal (aspirin/caffeine/
butalbital)*
Fiorinal w/Codeine (butalbital
compound
w/codeine)*
Flagyl (metronidazole)*
Flexeril (cyclobenzaprine)*
Flomax
Flonase (fluticasone)*
Florinef (fludrocortisone)*
Flovent HFA
Floxin Otic (ofloxacin)*
Floxin tablet (ofloxacin)*
Fluoroplex
fluvoxamine
FML Forte
FML Liquifilm
(fluorometholone)*
Folate (folic acid)*
Foradil
Fosamax (alendronate)*
Fosamax Solution
Fosrenol
Furadantin
Furoxone
Fuzeon
G
Gabitril
Gantrisin
Garamycin (gentamicin)*
Gel-Kam Gel (stannous
fluoride)*
Geodon
Gleevec
Glucagon
Glucophage (metformin)*
Glucophage XR (metformin ER)*
Glucotrol XL (glipizide XL)*
Glucovance (glyburide/
metformin)*
Glynase PresTab (glyburide
micronized)*
Glyset
Golytely Solution (PEG–
electrolyte for solution)*
Granulex (trypsin/balsam peru/
castor oil)*
Gynodiol (estradiol)*
H
Halcion (triazolam)*
Halflytely
haloperidol
Hectorol
Histussin HC (phenyleph/
chlorphen/hydrocodone)*
Humalog
Humibid DM
(dextromethorphan/
guaifenesin)*
Humibid LA (guaifenesin)*
Humulin R, N, 50/50, 70/30
Hycodan Syrup (hydrocodone
w/homatropine)*
Hydrea (hydroxyurea)*
hydrochlorothiazide
Hytone (hydrocortisone 2.5%
cream, ointment, lotion)*
Hytrin (terazosin)*
Hyzaar
I, J
Ilotycin (erythromycin)*
Imdur (isosorbide
mononitrate)*
Imitrex (sumatriptan)*
Imodium (loperamide)*
Imuran (azathioprine)*
Inderal (propranolol)*
Inderal LA (propranolol la)*
Inderide (propranolol/HCTZ)*
Indocin, SR (indomethacin, SR)*
Inflamase Mild, Forte
(prednisolone)*
Intal Inhaler
Intal Solution (cromolyn)*
Invirase
ISMO (isosorbide mononitrate)*
isoniazid
Isoptin, SR (verapamil, SR)*
Isopto Atropine (atropine
sulfate)*
Isopto Carpine
(pilocarpine HCl)*
Isopto Homatropine
(homatropine)*
isosorbide dinitrate
Janumet
Januvia
K
K-Lor (potassium chloride
20mEq)*
K-Lyte CL (potassium bicar/
chloride 25mEq)
K-Phos
K-Phos Neutral
(phospha 250)*
K-Tab (potassium chloride sr)*
Kaletra
Kayexalate (sodium
polystyrene sulfonate)*
Keflex (cephalexin)*
Kenalog in Orabase
(triamcinolone acetonide)*
Keppra (levetiracetam)
Kerlone (betaxolol)*
Klonopin (clonazepam)*
Klor-con
Kuzyme
Kytril (granisetron)*
L
Lamictal chewables 2mg
Lamictal chewables
5 & 25mg (lamotrigine)*
Lamictal tabs (lamotrigine)
Lamisil tablet (terbinafine)*
Lanoxin
Lanoxicaps
Lantus
Lariam (mefloquine)*
Lasix (furosemide)*
leucovorin
Leukeran
Leukine
Levaquin
Levbid (hyoscyamine)*
Levemir
Levlen (levonorgestrel & ethinyl
estradiol)*
Levo-Dromoran (levorphanol
tartrate)*
levora
Levothroid
Levoxyl
Levsin (hyoscyamine)*
Levsinex (hyoscyamine)*
Lexapro
Lexiva
Lialda
Librium (chlordiazepoxide)*
Lidex, E (fluocinonide)*
Lidoderm
Limbitrol DS (amitriptyline/
chlordiazepoxide)*
Lioresal (baclofen)*
Lipitor
Lithobid (lithium)*
Lo/Ovral (low-ogestrel)*
Lodine (etodolac)*
Lodine XL (etodolac ER)*
Loestrin FE (microgestin 1-20,
1.5/30)*
Lomotil (diphenoxylate/
atropine sulfate)
Loniten (minoxidil)*
Lopid (gemfibrozil)*
Lopressor (metoprolol)*
Lopressor HCT (metoprolol/
HCTZ)*
Loprox gel (ciclopirox)*
Loprox Shampoo
Lorcet (hydrocodone/apap)*
Lortab (hydrocodone/apap)*
Lotemax
Lotensin (benazepril)*
Lotensin HCT
(benazepril HCTZ)*
Lotrel 2.5/10, 5/10, 5/20
& 10/20 (amlodipine/
benazepril)*
Lorel 5/40 & 10/40mg
Lotrisone (clotrimazole/
betamethasone)*
Lovaza
Loxitane (loxapine)*
Lozol (indapamide)*
Lufyllin (dyphylline)*
Lupron (leuprolide)*
Lumigan
Luride (sodium flouride)*
M
Macrobid (nitrofurantoin
mono)*
Macrodantin (nitrofurantoin)*
Marinol (dronabinol)*
Materna (multi-vitamins
w/folic acid)*
Matulane
Mavik (trandolapril)*
Maxalt, MLT
Maxidex
Maxitrol (neomycin/polymyxin/
dexamethasone)*
Maxzide (triamterene/HCTZ)*
Mebaral (mephobarbital)*
Meclomen (meclofenamate)*
Medrol 4mg, 8mg
(methylprednisolone)*
Medrol 2 mg, 16mg, 32mg
Megace (megestrol)*
Mellaril (thioridazine)*
Menest
meperidine w/promethazine
Mephyton
Mepron
Mestinon timespan
Metaglip (glipizide/metformin)*
Methergine Tabs
methyclothiazide
MetroCream
(metronidazole)*
MetroGel
MetroGel Vaginal
(metronidazole vag)*
27
Metrolotion
(metronidazole lot)*
Mevacor (lovastatin)*
Mexitil (mexiletine)*
Micro-K (potassium chloride)*
Micronase (glyburide)*
Microzide (hydrochlorothiazide
caps)*
Midamor (amiloride)*
Midrin (isometh/dichlphen/
APAP)*
Minipress (prazosin)*
Minocin Capsule (minocycline)*
Mintezol
Miralax (glycolax)*
Mirapex
Mircette (kariva)*
Mobic (meloxicam)*
Modicon (ethinyl estradiol/
norethindrone)*
Monistat-Derm (miconazole
nitrate)*
Monodox (doxycycline
monohydrate)*
Monoket (isosorbide
mononitrate)*
Monopril (fosinopril)*
Motrin (ibuprofen)*
MS Contin (morphine SR)*
MSIR (morphine sulfate)*
Mucomyst (acetylcysteine)*
Myambutol (ethambutol)*
Mycobutin
Mycolog II (nystatin/
triamcinolone)*
Mycostatin (nystatin)*
Mydriacyl (tropicamide)*
Myleran
Mysoline (primidone)*
N
Naldecon (decongestabs)*
Nalfon 600mg (fenoprofen)*
Namenda
Naprosyn (naproxen)*
Nardil
Nasarel (flunisolide)*
Nasonex
Natafort (prenatal vitamin)*
Natalins (prenatal multivitamins
and minerals/iron/fa)*
Navane (thiothixene)*
Nebupent
necon
NeoDecadron (neomycin/
dexamethasone)*
neomycin
Neoral
Neosporin soln (neomycin/
polymyxin/gramicidin)*
Neosporin oint (neomycin/
polymyxin/bacitracin)*
NeoSynephrine
(phenylephrine)*
Neptazane (methazolamide)*
Neurontin (gabapentin)*
Neurontin Soln
Nexium
Niaspan
Niferex-150 Forte (iron/B12/
folic acid)*
Nilandron
Nitro-Bid (nitroglycerin SR)*
Nitro-Dur
Nitrol (nitroglycerin ointment)*
Nitrolingual spray
Nitrostat (nitroglycerin)*
Nizoral (ketoconazole)*
Noctec (chloral hydrate)*
Nolvadex (tamoxifen)*
Nor-QD (norethindrone)*
Nordette (levora)*
Norflex (orphenadrine)*
Norgesic (orphenadrine cpd)*
Norgesic Forte (orphenadrine
cpd Forte)*
Norinyl (necon)*
Normodyne (labetalol)*
Norpace (disopyramide)*
Norpace CR 100mg
Norpace CR 150mg
(disopyramide CR 150mg)*
Norpramin (desipramine)*
nortriptyline
Norvasc (amlodipine)*
Norvir
Novafed A (pseudo-ephedrine
hcl/chlor-mal)*
NuLev (neosol)*
Nuvigil
Nystatin
O
Ocufen (flurbiprofen sodium)*
Ocuflox (ofloxacin)*
Ocupress (carteolol hcl)*
Ogen (estropipate)*
Omnicef (cefdinir)*
Omnipen (ampicillin)*
One Touch Product Line
Opticrom (cromolyn)*
Optivar^ (azelastine)*
Ortho-Cept (apri, reclipsen)*
Ortho-Est (estropipate)*
Ortho Evra
Ortho-Novum (necon)*
Ortho Tri-Cyclen (tri-nessa)*
Ortho Tri-Cyclen Lo
Orudis (ketoprofen)*
Oruvail (ketoprofen SA)*
Ovral (ogestrel)*
OxyContin (oxycodone ER)
Oxytrol
P
Pamelor (nortriptyline)*
Pancrease
Panoxyl, AQ (benzoyl peroxide)*
Parafon Forte (chlorzoxazone)*
Paregoric
Parlodel Tab (bromocriptine)*
Parnate (tranylcypromine)*
Pataday
Patanol
Paxil (paroxetine)*
Paxil CR (paroxetine SR)*
Pediapred (prednisolone
sodium prosphate)*
Pediazole (erythromycin/
sulfisoxazole)*
Pentam (pentamidine
isethionate)*
Pentasa
Pepcid (famotidine)*
Percocet (oxycodone/APAP)*
Percodan (oxycodone/aspirin)*
Perforomist
Peridex (chlorhexidine
gluconate)*
Periostat (doxycycline)*
Persantine (dipyridamole)*
Phenergan DM (promethazine/
dextromethorphan)*
Phenergan VC syrup
(promethazine/
phenylephrine)*
Phenergan/Codeine
(promethazine/codeine)*
Phenergan (promethazine)*
Phenergan VC/Codeine
(phenylephrine/promethazine/
codeine)*
phenobarbital
Phoslo (calcium acetate)*
Pilocar (pilocarpine HCl)*
pindolol
Plan B 0.75mg (levonorgestrel)*
Plan B 1.5mg
Plaquenil (hydroxychloroquine)*
Plavix
Plexion SCT
Plexion TS (sulfacet sod w/
sulfur10/5%)*
Poly-Vi-Flor (multi-vitamins w/
fluoride)*
Polycitra (potassium citratecitric acid)*
Polycitra-K (Pot. & Sod. Citrates
w/citric acid)*
Polysporin (bacitracin zinc/
polymyxin B)*
Polytrim (polymyxin B/
trimethoprim)*
Potaba Tab (aminobenzoate
tab)*
potassium chloride
Pramosone 1% cream only,
lotion, oint
Prandin
Pravachol (pravastatin)*
Precose (acarbose)*
Pred Forte 1% (prednisolone)*
prednisone
Pred Mild 0.12%
Prelone (prednisolone)*
Premarin oral, vaginal cream
Premphase
Prempro
Prenate Advance
(prenatal w/docusate,
iron, folic acid)*
Prenate Elite
Prenate Ultra (multi-vitamins w/
folic acid)*
Prevacid (lansoprazole)*
Prevident (sodium fluoride)*
Prevpac
Priftin
Prilosec^ (omeprazole)*
Primaquine
Prinivil (lisinopril)*
Prinzide (lisinopril/hctz)*
Pristiq
ProAmatine (midodrine)*
ProAir HFA
Pro-Banthine (propantheline)*
probenecid
Procanbid
Procardia (nifedipine)*
Procardia XL (nifedipine ER)*
Proctocort (hydrocortisone)*
Proctocream-HC (hemorhoidal
cream)*
Profasi 10,000 (chorionic
gonadotropin)*
Prograf (tacrolimus)
Prolixin (fluphenazine)*
Proloprim (trimethoprim)*
Prometrium
Pronestyl, SR
(procainamide, SR)*
Propine (dipivefrin HCl)*
propylthiouracil
Proscar (finasteride)*
Protopic
Proventil HFA
Proventil, Tab, Syrup
(albuterol)*
Provera (medroxyprogesterone)*
Prozac (fluoxetine)*
Psorcon (diflorasone
diacetate)*
Pulmicort Respules
Pulmicort Turbuhaler
Purinethol (mercaptopurine)*
pyrazinamide
Pyridium (phenazopyridine)*
Q
Questran, Lite (cholestyramine,
light)*
Quinaglute (quinidine
gluconate)*
Quinidex (quinidine sulfate)*
R
Ranexa
Razadyne, ER
(galantamine, sr)*
Rebetol (ribavirin)*
Reglan (metoclopramide)*
Relafen (nabumetone)*
Remeron, SolTab (mirtazapine)*
Renagel
Renvela tab
Requip* (ropinirole)
Rescriptor
Restasis
Restoril (temazepam)*
Retin-A Cream (tretinoin)*
Retin-A Gel (tretinoin)*
Retin-A Micro
Retrovir
Revia (naltrexone hcl)*
Reyataz
Rheumatrex Tablets
(methotrexate tablets)*
Ridaura
Rifadin (rifampin)*
Rifamate
Rifater
Rilutek
Risperdal (risperidone)*
Risperdal Consta
Risperdal ODT, M-tab
(risperidone)*
Ritalin, SR (methylphenidate,
SR)*
RMS Supp (morphine)*
Robaxin (methocarbamol)*
Rocaltrol (calcitriol 0.25, 0.5
mg caps)*
Rondec DM syrup
(pseudoephed/bromphen-DM
45-4-15)*
Rondec, TR (pseudoephedrine/
carbinoxamine)*
Roxicodone (oxycodone)*
Rynatan (chlorphen/pyrilamine/
phenylephrine)*
Rynatuss tablets, pediatric
susp (phenyleph- ephed-cpd
w/carbetapentane)*
Rythmol (propafenone)*
S
Salagen (pilocarpine)*
Sandimmune*
Sandostatin (octreotide
acetate)*
Seasonale (jolessa, quasense)*
Sectral (acebutolol)*
Selsun (selenium sulfide)*
Septra, DS (sulfamethoxazole/
trimethoprim, DS)*
Serax (oxazepam)*
Serevent Diskus
Serophene (clomiphene)*
Seroquel, XR
Silvadene (silver sulfadiazine)*
Sinemet (carbidopa/levodopa)*
Sinemet CR (carbidopa/
levodopa CR)*
Sinequan (doxepin)*
Singulair
Skelaxin
Slo-Bid (theophylline)*
Slo-Phyllin 80 Syrup
(theophylline anhydrosl)*
Sodium Sulamyd (sulfacetamide
solution)*
Solaquin Forte (hydroquinone)*
Soma (carisoprodol)*
Somavert
Somophyllin (aminophylline)*
Sonata (zaleplon)*
Sorbitrate (isosorbide
dinitrate)*
Spectazole (econazole)*
Spiriva
Sporanox (itraconazole)*
Stadol N.S. (butorphanol
tartrate 10 mg/ml N.S.)*
Starlix (nateglinide)
Stelazine
(trifluoperazine)*
Strattera
Subutex (buprenorphine)*
Sular 20, 30 & 40mg
(nisoldipine)*
Sular 8.5, 17, 25.5 & 34mg
Sulfacet-R (sodium
sulfacetamide/sulfur)*
Sultrin (triple sulfa)*
Sustiva
Symbicort
Symbyax
Symlin
Symmetrel (amantadine)*
Synalar (fluocinolone
acetonide)*
Synthroid
(levothyroxine)
T
Tagamet (cimetidine)*
Talacen (pentazocine/apap)*
Talwin NX (pentazocine nx)*
Tambocor (flecainide)*
Tavist syrup, 2.68mg tabs
(clemastine fumarate)*
Tazorac
Tegretol (carbamazepine)
Tegretol XR
(carbamazepine ER)
Tekturna, HCT
Temodar
Temovate (clobetasol)*
Tenex (guanfacine)*
Tenoretic (atenolol/
chlorthalidone)*
Tenormin (atenolol)*
Terazol (terconazole)*
Teslac
Tessalon Perles (benzonatate)*
Testim
Theo-24
Theochron (theophylline)*
Thorazine Tab
(chlorpromazine tab)*
Ticlid (ticlopidine)*
Tigan (trimethobenzamide)*
Tilade
Timoptic (timololophthalmic)*
Timoptic XE (timolol)*
Tobi
Tobradex oint.
Tobradex susp. (tobramycin/
dexamethasone)*
Tobrex Soln (tobramycin)*
Tofranil (imipramine)*
Tolectin (tolmetin)*
Topamax
Topicort
(desoximetasone)*
Toprol XL (metoprolol)*
Toradol (ketorolac
tromethamine)*
Trandate (labetalol)*
Transderm-Scop
Tranxene (clorazepate)*
Trental (pentoxifylline)*
Treximet
Tricor (fenofibrate)*
TriLeven (levo norgestrel)*
Tri-Vi-Flor (triple vitamins
w/fluoride)*
Tridesilon (desonide)*
Trilafon (perphenazine)*
Trileptal (oxcarbazepine)*
Trilipix
Trimox (amoxicillin)*
Trimpex (trimethoprim)*
Trinsicon (iron/intrinsic factor/
B12)*
Triphasil (trivora)*
Trizivir
Trusopt (dorzolamide)*
Tussi-12 (phenyleph/chlorphen/
carbeta)*
Tussi-Organidin NR
(guaifenesin/codeine)*
Tussi-Organidin NR
DM (guaifenesin/
dextromethorphan)*
TussiCaps
28
Tussionex Pennkinetic ER
Twinject
Tylenol w/Cod
(codeine/APAP)*
Tylox (oxycodone
w/acetaminophen)*
Tympagesic (pramoxine/hc/
chloroxylenol)*
U
Ultracet
(tramadol/APAP)*
Ultram, ER (tramadol)*
Ultrase (pancrelipase)
Ultravate (halobetasol)*
Uniphyl
(theophylline SR)
Uniretic (moexipril/hctz)*
Unithroid
(levothyroxine)
Univasc (moexipril)*
Urecholine
(bethanechol)*
Urised (meth/salicylate/
atropine/hyos benzoic)*
Urocit-K (potassium citrate)*
Urogesic Blue (methenamine/
hyosc-meth blue/sod biphosphenyl sal)*
Uroxatral
V
V-Cillin K (penicillin V.K.)*
Vagifem
Valcyte
Valisone (betamethasone
valerate)*
Valium (diazepam)*
Valtrex (valacyclovir)
Vantin (cefpodoxime)*
Vaseretic (enalapril/
hydrochlorothiazide)*
Vasocidin (sulfacetamide
sodium-prednisolone
ophth sol.)*
Vasocon (naphazoline)*
Vasotec (enalapril)*
Venlafaxine ER
Vepesid (etoposide)*
Veramyst
Verelan (verapamil SR)*
Vermox (mebendazole)*
VESIcare
Vibramycin (doxycycline)*
Vicodin
(hydrocodone/APAP)*
Vicodin E.S. (hydrocodone/
apap)*
Videx
Videx EC (didanosine)*
Vigamox
Viokase
Viracept
Viramune
Viread
Viroptic (trifluridine)*
Vistaril (hydroxyzine pamoate)*
Vivelle
Vivelle Dot
Voltaren Gel
Voltaren Ophth
(diclofenac sodium)*
Voltaren, XR (diclofenac, ER)*
Vosol (acetic acid)*
Vosol HC (acetic acid/
hydrocortisone)*
Vyvanse
W, X
Welchol
Wellbutrin, SR (bupropion)*
Wellbutrin XL
(budeprion XL)*
Westcort (hydrocortisone)*
Xalatan
Xanax (alprazolam)*
Xopenex Neb Soln
(levalbuterol)
Xylocaine (lidocaine)*
Xylocaine viscous
(lidocaine viscous)*
Y, Z
Yasmin (ocella)*
Yaz
Yodoxin
Yocon (yohimbine)*
Zanaflex (tizanidine)*
Zantac (ranitidine)*
Zarontin (ethosuximide)*
Zaroxolyn (metolazone)*
Zebeta (bisoprolol)*
Zenate (multi-vitamins
w/folic acid)*
Zephrex LA (pseudoephedrine/guaifenesin)*
Zerit (stavudine)*
Zestril (lisinopril)*
Zestoretic (lisinopril/hctz)*
Zetacet (sulfacetsod w/sulfur
10/5%)*
Ziac (bisoprolol/HCTZ)*
Ziagen
Zithromax (azithromycin)*
Zocor (simvastatin)*
Zofran (ondansetron)*
Zoloft (sertraline)*
Zomig, ZMT
Zonegran
(zonisamide)*
zovia
Zovirax Cap (acyclovir)*
Zovirax Oint
Zylet
Zyloprim (allopurinol)*
Zyprexa
Your health plan is committed to helping you to manage your prescription benefits. Prior Authorization, Quantity Limits, Step Therapy and
Dose Optimization are some of the edits recommended by the P&T Committee and approved by your health plan. These edits help ensure
you have access to safe, appropriate and effective prescription medications.
PRIOR AUTHORIZATION: medications which require pharmacy benefit manager or plan approval before you may receive benefits.
Actiq (fentanyl citrate)*
Androderm
AndroGel
Botox*
Enbrel*
Fentora*
Forteo*
Genotropin*
Gleevec
Humatrope*
Humira*
Lamisil tablet (terbinafine)*
Lyrica*
Norditropin*
Nutropin, AQ*
Nuvigil
Pegasys*
Peg-Intron*
Penlac*
Provigil*
Remicade*
Saizen*
Serostim*
Sporanox (itraconazole)*
Testim
Tev-Tropin*
Topamax
Xeloda
Xolair*
Xyzal*^
Zorbtive*
Zyvox*
QUANTITY LIMIT: affects the frequency or dosage of certain medications for which you receive benefits.
Aciphex*^
Actiq (fentanyl citrate)*
Advicor
Allegra^ (fexofenadine)*
Allegra D^ (fexofenadine/
PSE 12hr)*
Ambien (zolpidem)*
Ambien CR*
Amerge*
AndroGel
Anzemet*
Astelin
Astepro
Avinza
Axert*
Byetta
Clarinex, D*^
Crestor
Cymbalta
Diabetic Test Strips
(Accu-Chek and One Touch
brand products are formulary)
Elestat*^
Emend*
Enbrel*Fentora*
Flonase (fluticasone)*
Forteo*
Frova*
Genotropin*
Humatrope*
Humira*
Imitrex (sumatriptan)*
Kapidex*
Kytril (granisetron)*
Lunesta*
Maxalt, MLT
Migranal*
Nasonex
Nexium*
Norditropin*
Nutropin, AQ*
Nuvigil
Optivar^ (azelastine)*
Pataday
Patanol
Prevacid (lansoprazole)*
Prilosec^ (omeprazole)*
Pristiq
Protonix^
(pantoprazole#^)*
Relpax*
Rozerem*
Saizen*
Serostim*
Simcor*
Sonata (zaleplon)*
Stadol N.S. (butorphanol)*
Symbicort
Testim
Tev-Tropin*
Treximet
Veramyst
Xyzal*^
Zofran (ondansetron)*
Zomig, ZMT
Zorbtive*
STEP THERAPY: requires that you first use a specific medication before alternatives therapies may be tried or prescribed.
Elidel
Protonix^
Adderall (amphetamine/
Beconase AQ*
Xyzal*^
(pantoprazole#^)*
dextroamphetamine^#)
Kapidex*
Zetia*
Betaseron*
Protopic
– generic only
Nasacort AQ*
Byetta
Rhinocort Aqua*
Aciphex*^
Celebrex*
Rozerem*
Omnaris*
Diabetic
Test
Strips
(AccuAmbien CR*
Sonata (zaleplon)*
Chek and One Touch brand Prevacid*
products are formulary)
Prilosec*^
Arthrotec*
Vytorin*
DOSE OPTIMIZATION: normally involves the conversion from twice-daily dosing to a once-daily dosing schedule. A once-daily dosing schedule
may increase compliance and decrease expenses for you and your health plan.
Medications in the following categories are included in the dose optimization edits.
Antidepressants Cholesterol reducing medications Certain blood pressure medications
Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization
or quantity limits, contact Member Services at the telephone number listed on your identification card.
KEY
Generic Medication – (lowest copay) – listed in all lowercase letters
Brand-name Medications – (middle copay) – listed with a leading capital letter
* – Brand versions of these drugs are non-formulary (highest copay)
^ – This product has clinically equivalent alternatives included on the formulary and, as
a consequence, such product may not be covered under your pharmacy benefit.
Please consult your on-line pharmacy account through your health plan website, empireblue.com, for details on coverage.
29
For more information, please visit empireblue.com.
●
If you have additional questions about your prescription benefits,
please call the Member Services number on your ID card.
●
Individuals who have a speech or hearing impairment (TDD/TTY users)
should call 800-221-6915, Monday – Friday, 8:30 a.m. – 5:00 p.m. ET.
●
For the most current version of this prescription drug list, please visit
empireblue.com.
●
Bring a copy of this drug list/formulary to your next doctor’s visit to
assist in selecting the lowest cost medications.
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc.,
licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross
and Blue Shield plans.
® Registered marks Blue Cross and Blue Shield Association.
MNYFM6596YLG RxFormulary EBCBS 01/10
30
Mail Order and Other Prescription Benefits
With Empire prescription benefits, you have access to over 62,000 chain and independent
pharmacies across the country. No matter if you’re at home or traveling across the U.S., there
should be an Empire participating pharmacy near you. Simply go to empireblue.com to find
one. Then just show your member ID card to the pharmacist. You also have access to
a convenient mail service pharmacy, NextRx.
NextRx can save you money.
If you routinely take a medication, your pharmacy benefit lets you fill a prescription through
the NextRx mail service pharmacy for up to a 90-day supply at a time. This can save you money,
because with most plans, you only pay a two-month co-pay for a three-month prescription.
Over a year’s time, that can add up to four months of refills at no additional cost to you! Also,
you don’t have to go anywhere to get your prescription. It’s delivered right to your door. Did we
mention the shipping is free?
5 Easy Steps to Get Started
1. For medications you take year-round, ask your doctor to write your prescription for the
maximum supply allowed based on your medical needs (typically a 90-day supply).
2. Complete the order form in this booklet.
3. Mail both prescription and form with your payment to NextRx (the address is on the form).
4. Watch your mailbox for your order to arrive.
5. You can also check your prescription status online at empireblue.com
Or, if you prefer, you can simply call our toll-free number and a customer care associate
will gladly call your prescribing physician to get the mail service prescription for you. And
there’s nothing further you need to do.
Thought that was easy? Wait until you need a refill. It takes just a few clicks of the keyboard
and mouse and your order is placed.
3 Easy Ways to Get Refills
1. Online: empireblue.com
2. By phone: Monday through Friday, 8:30 a.m. to 8 p.m., Eastern time.
3. By mail: using the mail order form included with your prescription
For your convenience, you’ll also get a refill reminder call. You can easily place your refill
order at that time.
Benefit plans may vary by employer. See your evidence of coverage or medical policy for
what you’ll pay through mail service. If you need a copy, talk to your benefits manager.
MNYSH6540Y RxBenefits
31
Mail Order and Other Prescription Benefits
(continued)
Other great features of Empire prescription benefits:
}
You typically pay the least with generics. Generic medications are required by the Food
and Drug Administration (FDA) to be as effective as their brand-name counterparts. So they
contain the same active ingredients and must meet certain qualifications. But generics
are different from brand names in one important way — they cost up to 70 percent less.
Which is why you pay the lowest copay when you use generics. Talk to your physician or
pharmacist about generic medications and if they are appropriate for you.
}
You can protect your health and your wallet by using the formulary/drug list. A
formulary or drug list is a list of prescriptions recommended for their safety, quality and
cost effectiveness. Your costs are lower when you and your physician choose medications
from the formulary or drug list. Medications not on the list are still covered, but will cost
you more at the pharmacy. Your formulary/drug list is enclosed in this booklet. The list can
change due to drugs going on and off the market and other factors. You can get the most
up-to-date list at empireblue.com.
}
You’re further protected by our warning alerts. Your prescription benefit may include
what we call “clinical edits.” These are rules put in place to help assure safe, appropriate
use of medications and help reduce the risk of possible medication dangers. How it works
is that when your pharmacist enters your prescription data, our computer system runs a
check of the medication such as correct dosage amount or to see if there is a lower cost
alternative. If your prescription generates an alert, your pharmacist is immediately notified.
A prime example of this is the “pregnancy category X edit” that monitors instances where
a prescribed medication may be inappropriate for customers who are pregnant. Pregnancy
category X drugs reject if prenatal vitamins are in a customer’s recent history.
The rules put in place for your plan may include prior authorization, step therapy, quantity
limits, duplicate therapy, dose optimization and refill-too-soon. However, not all employer
plans and medications are subject to the rules for prior authorization, step therapy or
quantity limits. Talk with your benefits manager for the specifics of your plan.
contains the details. See your benefits manager if you need a copy.
Thank you for considering Empire.
MNYSH6540Y RxBenefits
32
Envíe por correo el formulario de pedidos completo, la(s) receta(s) original(es) y el pago a: NextRx, PO Box 746000, Cincinnati, OH 45274-6000.
Si tiene más de una receta, incluya cada una de ellas junto con el formulario de pedido. Usted podrá incluir los formularios que estime conveniente.
Sección 1: Información del miembro
Ingrese la información del afiliado o del titular de la póliza, según se indique en la tarjeta de beneficios o en el plan de salud. No escriba al dorso de este formulario.
Nombre del plan de salud
Número de identificación
Apellido del afiliado o del titular de la póliza
Nombre
Inicial
Fecha de nacimiento (mm/dd/aaaa)
/
/
Sección 2: Información de envío
Los pedidos se envían en un plazo de siete días a partir de la recepción del pedido válido. Los medicamentos refrigerados y controlados no se pueden enviar a una casilla de
correo. Las sustancias controladas por el programa II requieren de una firma para la entrega correspondiente.
Nueva dirección
Sí
Calle
Departamento/suite
No
Ciudad
Estado
Código postal Número de teléfono diurno (incluido el código de área)
Dirección de correo electrónico
Número de teléfono nocturno (incluido el código de área)
Sección 3: Información de pagos
El pago deberá abonarse antes de efectuar el envío de un pedido. No envíe efectivo. Haga los cheques y los giros postales pagaderos a NextRx. En el caso de cheques
devueltos, habrá un cargo de $25. Las tarjetas de crédito reciben el cargo completo y se usan para futuro pedidos, a menos que se especifique un nuevo método de pago. Los
envíos urgentes no agilizan el tiempo de procesamiento de las recetas.
Método de pago:
Número de cuenta
Cheque
Visa
MasterCard
American Express
Fecha de vencimiento
Firma/fecha
Monto adjunto:
Discover
Envío en 24 horas (agregue $20)
Código del cupón:
Surtir la(s) receta(s) que esté(n) registrada(s) en los archivos más adelante.
Sección 4: Información relacionada con la receta médica
Se entregarán medicamentos genéricos, que tengan aprobación federal, en lugar de sus equivalentes de marca, a menos que el paciente, el médico o el plan de salud indique lo
contrario.
Nombre
Apellido del paciente
Inicial Fecha de nacimiento (mm/dd/aaaa )
/
Alergias a medicamentos (marque todo lo que corresponda):
Penicilina
Aspirina Codeína
Sexo
H
/
M
Sulfamida
Otros (enumere todos, incluidos los medicamentos sin prescripción médica)
Antecedentes médicos (marque todo lo que corresponda):
Tiroides
Cardiopatía
Asma
Medicamentos recetados nuevos: nombre del medicamento
Nro. de pedidos de reposiciones:
Diabetes
Glaucoma
Hipertensión
Artritis
Otros (enumere todos)
Apellido del médico
Tomados anteriormente
Sí
No
Sí
No
Sí
No
Marque la casilla para
surtir la(s) receta(s) que
están en los archivos
más adelante.
Nombre del medicamento
Si desea obtener servicios de traducción, comuníquese al 877-373-6770. NextRx, PO Box 746000, Cincinnati, OH 345274-6000
3
PBM-90a | 102008
Mail your completed order form, original prescription(s) and payment to: NextRx, PO Box 746000, Cincinnati, OH 45274-6000.
If you have multiple prescriptions, include all prescriptions with the order form. You may duplicate the order form as needed.
SECTION 1: MEMBER INFORMATION
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SECTION 2: SHIPPING INFORMATION
Orders ship within seven days of receipt of valid order. Controlled and refrigerated medications cannot ship to a PO box. Schedule II controlled substances require signature on delivery.
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SECTION 3: PAYMENT INFORMATION
Payment is required before an order will ship. Do not send cash. Make checks and money orders payable to NextRx. There is a $25 fee for returned checks. Credit cards
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SECTION 4: PRESCRIPTION INFORMATION
Federally approved, generic-equivalent medications will be dispensed for brand name medications unless otherwise directed by the patient, physician, or health plan.
If you require brand medications, please use the comments section below and list the names of the medications. Brand may be subject to higher cost.
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Language translation services available at 877-373-6770. NextRx, PO Box 746000, Cincinnati, OH 45274-6000
PBM-90a | 072009
Express Scripts, Inc. (ESI) is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. WellPoint NextRx, NextRx and PrecisionRx are registered trademarks of WellPoint, Inc. and are used under license agreement by ESI.
35
Empire Blue View Vision
SM
Vision care is not just for eyeglass wearers. Routine eye visits are important for everyone to
help preserve vision health. Eye exams can also help detect other health problems. Blue View
Vision helps you get the vision care you need without feeling like your busting your budget.
Advantages of Empire Blue View Vision:
}
You have access to eye doctors close to you. Blue View Vision has 44,000 eye doctors
and locations in its network. If you don’t already have a favorite, you can quickly find one.
Plus, many retail locations, like LensCrafters®, Target® Optical, Sears Optical, Pearle Vision®,
and New York-based Empire and Davis Vision stores are covered by the plan.
}
Blue View Vision helps pay for routine eye exams. See your evidence of coverage or
vision policy for details.
}
Not many plans are this simple. Just schedule an appointment with a network provider
and present your member ID card when you arrive. The doctor’s office staff will take care
of the rest. And in most instances, you just need to pay a low copayment.
}
You save even more with additional discounts. Want spare glasses, contact lenses or
prescription sunglasses? Save 15 to 40 percent. Your additional discounts are unlimited,
even after your vision care benefits have exhausted. If your frames are covered and you
want a frame that costs more than your plan allows, you save 20 percent off the balance.
}
You’ve always got someone to help. If you’re seeing your eye doctor at night or on
weekends, that’s when we should be available to help you. So we’re open Monday through
Saturday, 8 a.m. to 11 p.m. Eastern time and Sunday 11 a.m. to 8 p.m. Eastern time. Or you
can reach the interactive voice response system most any time of the day.
How to find a Blue View Vision provider:
2. Select “Blue View Vision”
What happens if you use an eye professional not in the network?
You’re still covered, although you’ll pay less by staying in network. You’ll be asked to pay the
full cost for services at the time of your appointment. When you mail in your receipt and other
paperwork to Empire, you’ll get paid back for what the plan covers. To save the most money and
have less hassle, try to use an eye doctor or retail location in the network.
This is a brief overview of your plan’s features. Your evidence of coverage or vision policy
contains the details. See your benefits manager if you need a copy. Thank you for considering
Empire.
MNYSH6548Y BVV
37
¡BIENVENIDO A
BLUE VIEW VISION!
Buenas noticias: su plan de la visión
es flexible y fácil de usar. Este
resumen de beneficios describe los
elementos básicos de su plan e
incluye respuestas breves sobre qué
está cubierto, qué descuentos tiene,
¡y mucho más!
Blue View VisionSM
Descuentos en atención básica de los ojos y en artículos para los ojos
Su red de Blue View Vision
Blue View Vision le ofrece una de las redes de atención de la visión más grande de la industria, en la que participan
muchos oftalmólogos, optometristas y ópticos. Para su comodidad, la red de Blue View Vision también incluye tiendas
minoristas, muchas de las cuales atienden por la noche y los fines de semana, como LensCrafters®, Target Optical®,
JCPenney® Optical, Sears OpticalSM, Pearle Vision®, y los centros Empire Vision y Davis Vision en Nueva York.
Y lo mejor: cuando elija atenderse con un proveedor participante de Blue View Vision, recibirá todos los beneficios
dentro de la red y descuentos para cuidar su bolsillo.
Servicios fuera de la red
¿Le dijimos que somos flexibles? Le ofrecemos la opción de recibir atención fuera de la red de Blue View Vision. Si elije
un proveedor fuera de la red, recibirá una asignación para pagar un examen ocular, y usted pagará el resto. No se
aplicarán los beneficios y descuentos de la red. Cuando usted reciba atención de los ojos de un proveedor no
participante, pagará el costo completo en el momento del servicio y luego deberá presentar una reclamación de
reembolso a Blue View Vision, Attn: OON Claims, PO BOX 8504, Mason, OH 45040-7111.
Si tiene preguntas sobre sus beneficios de visión, llame al Servicio de Atención al Cliente de Blue View Vision: 866723-0515.
RESUMEN DE SU PLAN BLUE VIEW VISION:
SERVICIOS DE ATENCIÓN DE LA VISIÓN
Examen ocular de rutina (una vez cada 12 meses)
DENTRO DE LA RED
FUERA DE LA RED
Copago de $15
Asignación de $40
DESCUENTOS
Si desea conocer importantes descuentos en artículos para los ojos, consulte a su profesional para la atención de los ojos o al centro de la visión participantes de Blue
View Vision.*
* Blue View Vision ofrece descuentos a través de nuestro programa Additional Savings Program. Solicite más información a su representante de ventas o a su proveedor dentro de
la red.
CÓMO USAR SU PLAN BLUE VIEW VISION
La red de Blue View Vision es sólo para la atención de los ojos de rutina. Si necesita tratamiento médico para los ojos, visite a un médico para la atención de los ojos
que participe en su red médica.
EXCLUSIONES Y LIMITACIONES
Este es un beneficio para la atención primaria de los ojos. Sólo cubre exámenes oculares. Los servicios no cubiertos que se describen a continuación pueden adquirirse, a precios
preferidos, de un proveedor de Blue View Vision. Además, los beneficios de examen se pagan sólo por los gastos realizados mientras la cobertura del grupo y de la persona
asegurada esté en vigencia.
Ofertas combinadas. Servicios o suministros combinados con otra oferta, cupón o promoción de una
tienda.
Servicios experimentales o de investigación. Los servicios que son experimentales o de
investigación, o que se relacionen con éstos, ya sea que se realicen antes o después de dichos
servicios o suministros experimentales o de investigación, o en relación con éstos, según lo
determinemos nosotros, o que se reciban de un departamento médico o de visión mantenido por un
empleador, por una asociación de beneficios mutuales, un sindicato, un fiduciario u otra persona o
grupo similar, o en nombre de éstos.
Delitos o guerra. Las afecciones que sean resultado de lo siguiente: (1) la participación en un delito
grave, un motín o rebelión; o (2) enfermedades o lesiones sufridas como consecuencia de una
guerra, declarada o no, o de cualquier acto bélico.
Sin seguro. Servicios recibidos antes de la fecha de entrada en vigencia de la persona asegurada o
después de que finaliza la cobertura.
Sumas excedentes. No pagaremos ninguna suma superior a lo que cobró un proveedor de atención
de la visión por servicios cubiertos ni que sea superior a los cargos usuales; tampoco aceptaremos
dichas sumas para el cálculo del copago.
Exámenes o pruebas de rutina. Exámenes de rutina requeridos por un empleador a raíz del trabajo
de la persona asegurada.
En relación con el trabajo. Cualquier afección, enfermedad, defecto, dolencia o lesión que surjan
del empleo, o durante el curso de éste, si los beneficios están disponibles según una ley de
compensación a los trabajadores u otra ley similar. Esta exclusión se aplica ya sea que usted haya
recibido todos los beneficios o parte de ellos; ya sea que haya reclamado los beneficios o la
compensación, o no; ya sea que reciba resarcimiento de un tercero o no.
Tratamiento gubernamental. Si es brindado como beneficio por una entidad del gobierno, a menos
que las leyes o reglamentaciones exijan lo contrario.
Anteojos de sol. Anteojos de sol y marcos accesorios.
Gafas de seguridad. Gafas de seguridad y marcos accesorios.
Atención hospitalaria. No brindamos beneficios por servicios recibidos en un hospital del
gobierno o de una organización de beneficios públicos, a menos que tengamos un acuerdo de
participación o un acuerdo con dicho hospital (en este caso cubriremos sólo los servicios incluidos
en dicho acuerdo).
Ortóptica. El tratamiento de lesiones o enfermedades de los ojos, las pruebas de diagnóstico
adicionales y los procedimientos especiales, como los ejercicios de ortóptica, no están cubiertos
conforme a este Certificado.
Lentes no recetados. Anteojos, lentes o lentes de contacto no recetados. Lentes no correctivos
(lentes que no tienen efecto refractivo).
Lentes bifocales. Dos pares de anteojos en lugar de lentes bifocales.
Marcos y lentes rotos o perdidos. Reemplazo de marcos o lentes perdidos, robados, rotos o
duplicados.
Pagos voluntarios. No cubriremos ningún servicio que habitualmente se brinde sin cargo.
Turnos perdidos. No reembolsaremos el costo generado por un turno perdido o cancelado.
Servicios de familiares. Servicios o suministros recetados, ordenados, derivados o recibidos de
un miembro de su familia inmediata, incluido su cónyuge, hijo, hermano, hermana, padres,
suegros, abuelos o usted mismo.
Preexistentes. Trastornos o enfermedades.
Ejército. Servicios o suministros relacionados con el servicio en el ejército o en unidades
auxiliares de éste.
Artículos para los ojos. Lentes para anteojos, marcos y lentes de contacto.
Los proveedores dentro de la red mencionados en este comunicado tienen contrato en forma independiente y ejercen un criterio profesional independiente. No son agentes ni empleados de Anthem. Este documento de descripción general de
beneficios es sólo una parte de su paquete de inscripción. Las exclusiones y limitaciones figuran en el folleto de inscripción. Los servicios son proporcionados por Empire HealthChoice HMO, Inc. y/o Empire HealthChoice Assurance, Inc.;
licenciatarios de Blue Cross and Blue Shield Association, una asociación de los planes independientes de Blue Cross and Blue Shield. Los nombres y los símbolos de Blue Cross and Blue Shield son marcas registradas de Blue Cross and Blue
Shield Association.
39
360° Health®
Empire’s 360° Health is a valuable part of your health plan. It surrounds you with programs and
services that can help you get healthy, stay healthy and live better.
It’s a basic idea: the more you know, the healthier you can be. Instead of waiting for health
problems (and their costs) to crop up, these programs can help you prevent them or keep them
from getting worse. Best of all, 360° Health is built into your plan at no extra cost. The program
is just that important. And just that effective.
Many of the programs are online. To reach them, go to empireblue.com, register and log in with
your username and password.
Whatever stage of health you’re in, these core programs work together to support you.
Not all programs are available in all areas or to all groups and members. Talk to your employer
about which of these and other 360° Health programs may be part of your plan.
MyHealth — Finding health information online can be like using a dictionary that’s not
alphabetized. This personalized site makes it easy to find the info that matters to you, manage
your health and stay motivated.
24/7 NurseLine — Health questions and concerns don’t keep regular business hours. When
you need answers right away, you have direct, round-the-clock access to a registered nurse.
It’s tollfree and always confidential.
Future Moms — A healthy pregnancy may be the greatest gift you could give your baby. This
award-winning maternity program gives you support — and educational information — for every
stage of pregnancy.
Staying Healthy Reminders — You’re busy. Very busy. So we’ll help you remember to get those
preventive tests, procedures and screenings that can mean so much to your health. Well-timed
mailers targeted to your needs cover simple, potentially life-saving services ranging from
cancer screenings and immunizations to tips for safe recreational activity.
ConditionCare — Chronic diseases need continuous attention. Thankfully, you’re not alone
when facing difficult cases of asthma, diabetes, chronic obstructive pulmonary disease,
coronary artery disease or heart failure. If you qualify, you’ll have your own registered nurse
to help you self-manage your condition with the goal of improving your quality of life.
ComplexCare — This team of nurses specializes in helping people with specialty care needs
who might be at risk for even bigger problems in the future. With one-on-one attention and
coaching, your nurse will help you develop a personal care plan to help reduce that risk.
Anthem Care Comparison — Make more informed decisions about the medical care that
you and your family receive. This innovative online tool allows you to evaluate and compare
hospitals based on clinical quality measures and other key quality indicators, all within a given
radius of the area you choose. And you can also estimate the costs of specific health care
services and procedures; putting information and choices in your hands.
Comprehensive Medical Management — You’re not alone when facing a difficult health
crisis. With this program, you’ll get expert one-on-one help during critical times. Your medical
manager will make sure that your benefits work for you and that the care you access is
appropriate and safe. It’s like having your own personal health advocate.
MNYSH6553Y 360FI (7/09)
41
42
FAX to: 1-800-780-1224
Mail to: Empire
PO Box 1407
Church Street Station
New York, New York 10008-1407
STUDENT COVERAGE QUESTIONNAIRE
Member’s identification number:
Dependent’s name:
1. Dependent’s date of birth:
2. Relationship to member:
3. Is dependent:
Single
Married
Divorced
Separated
4. Is dependent employed?
Yes
Full-time
Part-time
No
5. List any other group insurance or pre-payment program the dependent is covered under:
6. Is the dependent a student
Yes
No
If yes:
Full-time
Part-time
7. School name and address:
8. Type of school (college, trade, etc.)
9. Expected date of:
Graduation
Course Completion:
10. Was the dependent a full-time student at an accredited school who is now on a leave of absence from
Yes No
the school due to illness or injury?
If yes, what is the name of the school attended prior to the medical leave?
What is the date the medical leave began?
(You must also attach a letter from the student’s doctor which documents his/her illness or injury and certifies
to the medical necessity of the leave of absence from the school)
I hereby certify that the above is correct to the best of my knowledge.
Signature of member
Date
I understand that any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall
also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Services provided by Empire HealthChoice HMO, Inc., and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
43
ENR 0286B 09/06
Important Information
MNYSH5967Y (1/09)
Important legal information you should
take time to read
Breast Reconstruction Surgery Benefits and Women’s Health and Cancer
Rights Act of 1998
If you are receiving covered benefits for a mastectomy, you should know that the Women’s
Health and Cancer Rights Act of 1998 provides for:
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The manner in which services are provided is between you and your physician. Coverage is
subject to all of the terms and conditions stated in your member certificate, including any
applicable deductible, co-payment and coinsurance. You may be entitled to additional benefits
as mandated by state law. Check your member certificate or contact Member Services at the
number located on the back of your Identification Card for details.
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HIPAA Notice of Privacy Practices (Effective July 1, 2007)
This notice describes how medical information about you may be used and disclosed and how
you can get access to this information.
We keep the health and financial information of our current and former members private
as required by law, accreditation standards, and our rules. This notice explains your rights.
It also explains our legal duties and privacy practices. We are required by federal law to give
you this notice.
Your Protected Health Information
We may collect, use, and share your Protected Health Information (PHI) for the following reasons
and others as allowed or required by law, including the HIPAA Privacy rule:
For Payment: We use and share PHI to manage your account or benefits; or to pay claims for
health care you get through your plan. For example, we keep information about your premium
and deductible payments. We may give information to a doctor’s office to confirm your benefits.
For Health Care Operations: We use and share PHI for our health care operations. For example,
we may use PHI to review the quality of care and services you get. We may also use PHI to
provide you with case management or care coordination services for conditions like asthma,
diabetes, or traumatic injury.
For Treatment Activities: We do not provide treatment. This is the role of a health care provider
such as your doctor or a hospital. But, we may share PHI with your health care provider so that
the provider may treat you.
MNYSH6554Y HIPAA-WHCRA
47
take time to read (continued)
To You: We must give you access to your own PHI. We may also contact you to let you know
about treatment options or other health-related benefits and services. When you or your
dependents reach a certain age, we may tell you about other products or programs for which
you may be eligible. This may include individual coverage. We may also send you reminders
about routine medical checkups and tests.
To Others: You may tell us in writing that it is OK for us to give your PHI to someone else for any
reason. Also, if you are present, and tell us it is OK, we may give your PHI to a family member,
friend or other person. We would do this if it has to do with your current treatment or payment
for your treatment. If you are not present, if it is an emergency, or you are not able to tell us it
is OK, we may give your PHI to a family member, friend or other person if sharing your PHI is in
your best interest.
As Allowed or Required by Law: We may also share your PHI, as allowed by federal law, for
many types of activities. PHI can be shared for health oversight activities. It can also be shared
for judicial or administrative proceedings, with public health authorities, for law enforcement
reasons, and to coroners, funeral directors or medical examiners (about decedents). PHI can
also be shared for certain reasons with organ donation groups, for research, and to avoid
a serious threat to health or safety. It can be shared for special government functions, for
workers’ compensation, to respond to requests from the U.S. Department of Health and Human
Services and to alert proper authorities if we reasonably believe that you may be a victim of
abuse, neglect, domestic violence or other crimes. PHI can also be shared as required by law.
If you are enrolled with us through an employer sponsored group health plan, we may share PHI
with your group health plan. We and/or your group health plan may share PHI with the sponsor
of the plan. Plan sponsors that receive PHI are required by law to have controls in place to keep
it from being used for reasons that are not proper.
Authorization: We will get an OK from you in writing before we use or share your PHI for any
other purpose not stated in this notice. You may take away this OK at any time, in writing.
We will then stop using your PHI for that purpose. But, if we have already used or shared your
PHI based on your OK, we cannot undo any actions we took before you told us to stop.
Your Rights
Under federal law, you have the right to:
}
}
}
}
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48
Call Customer Service at the phone number printed on your identification (ID) card to use any
of these rights. They can give you the address to send the request. They can also give you any
forms we have that may help you with this process.
How We Protect Information
We are dedicated to protecting your PHI. We set up a number of policies and practices to help
make sure your PHI is kept secure. We keep your oral, written, and electronic PHI safe using
physical, electronic, and procedural means. These safeguards follow federal and state laws.
Some of the ways we keep your PHI safe include offices that are kept secure, computers that
need passwords, and locked storage areas and filing cabinets. We require our employees to
protect PHI through written policies and procedures. The policies limit access to PHI to only
those employees who need the data to do their job. Employees are also required to wear ID
badges to help keep people who do not belong, out of areas where sensitive data is kept.
Also, where required by law, our affiliates and non-affiliates must protect the privacy of data
we share in the normal course of business. They are not allowed to give PHI to others without
your written OK, except as allowed by law.
Potential Impact of Other Applicable Laws
HIPAA (the federal privacy law) generally does not preempt, or override other laws that give
people greater privacy protections. As a result, if any state or federal privacy law requires us to
provide you with more privacy protections, then we must also follow that law in addition to HIPAA.
Complaints
If you think we have not protected your privacy, you can file a complaint with us. You may also
file a complaint with the Office for Civil Rights in the U.S. Department of Health and Human
Services. We will not take action against you for filing a complaint.
Contact Information
Please call Member Services at the phone number printed on your ID card. They can help you
apply your rights, file a complaint, or talk with you about privacy issues.
Copies and Changes
You have the right to get a new copy of this notice at any time. Even if you have agreed to get
this notice by electronic means, you still have the right to a paper copy. We reserve the right to
change this notice. A revised notice will apply to PHI we already have about you as well as any
PHI we may get in the future. We are required by law to follow the privacy notice that is in effect
at this time. We may tell you about any changes to our notice in a number of ways. We may tell
you about the changes in a member newsletter or post them on our Web site. We may also mail
you a letter that tells you about any changes.
49
State Notice of Privacy Practices
As we told you in our HIPAA notice, we must follow state laws that are more strict than the
federal HIPAA privacy law. This notice explains your rights and our legal duties under state law.
Your Personal Information
}
}
}
}
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A more detailed state notice is available upon request. Please call the phone number printed
on your ID card.
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50
Don’t skip this section!
This notice explains when you and your dependents not covered by Empire have the right to
enroll on a special basis.
Your Special Enrollment Rights
If you choose not to enroll in an Empire health plan, there are special times when you and your
eligible dependents can do so.
If you decline to enroll yourself or your dependents (including your spouse) because you have
other health insurance or group health plan coverage, you may be able to enroll yourself and
your dependents in this plan at a later time. This would occur if you or your dependents lose
eligibility for that other coverage (or if the employer stops contributing towards your or your
dependents’ other health coverage). However, you must request enrollment within 30 days
after your or your dependents’ other coverage ends (or after the employer stops contributing
toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption or
placement for adoption, you may be able to enroll yourself and your dependents. However,
you must request enrollment within 30 days after the marriage, birth, adoption or placement
for adoption.
Examples
Example 1 — Loss of other coverage: You and your family are enrolled through your spouse’s
coverage at work. Your spouse’s employer stops paying for coverage. In this case, you and
your spouse, as well as other dependents on your policy, may be eligible to enroll in one of our
health plans.
Example 2 — You have a new dependent: You get married. You and your spouse and any other
new dependents may be eligible to enroll in the plan.
You have 30 days to enroll
In each case, you may apply for enrollment with us within 30 days after:
}
The other coverage ends.
}
The employer stops contributing toward the other coverage.
}
The marriage, birth, adoption or placement for adoption.
To request a special enrollment or obtain more information, contact Member Services
at 800-662-5193.
MNYSH6556Y EnrollRights
51
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the
Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue
Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
MNYBC5966Y (1/09)

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