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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 benef ts come with your Empire coverage. It summarizes what's available to you, what you get with each benef t 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 satisf e i d members access the health care they need.  There's a good chance your doctor is part of Empire's network. To f n
i d 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 benef t
i s 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 f n i d detailed health benef ti 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 f v i e 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, f n i d 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. *Based on lists in New York Magazine 6/08/08 issue and searches of competitors' web sites. MNYSH6525Y Welcome Ltr Table of Contents Plan Overview .7 Benefit Summaries .15 Ancillary Benefits .21 Important Information .43



Plan Overview
MNYSH5967Y (1/09) Empire PrismSM 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.
Empire PrismSM 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
1. Go to empireblue.com 2. Select "Find a Doctor" 3. Select your plan: Empire Prism PPO 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.
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 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:
MNYSH6538Y DecSupTools 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.
Registering is easy.
8ccpfle [ jpfli@;ZXi["k_ @ek ie kXe[] m d elk j% 1. Go to empireblue.com 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. 1Vendors 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.
MNYSH6538Y DecSupTools


Benefit Summaries
MNYSH5967Y (1/09) Your Summary of Benefits
Prism EPO
Country Life LLC
In-Network1
Lifetime Maximum Dependent Children (covered to end of calendar year) To age 19 ; ful -time students to age 23 Preventive Care6
Member Pays
Adult Preventive Care Annual Physical Exam Wel -Child Care (to age 19; Including covered immunizations) Home/Office/Outpatient Care7
Member Pays
Home/Office Visits Emergency Room/Facility (initial visit per occurrence) $100 copay (waived if admitted within 24 hours) Ambulatory Surgery3/Outpatient Surgery $200 copay per visit Presurgical Testing, Anesthesia Chemotherapy, Radiation Therapy Laboratory Tests, X-rays6 MRI2/MRA2, CAT Scan2, PET2 & Nuclear Cardiology2 $50 copay per service Chiropractic Care5 Home Healthcare (Up to 200 visits per calendar year) Home Infusion Therapy Hospice Care (Up to 210 days combined IP & OP per lifetime) Physical Therapy3 (Up to 60 visits per calendar year combined in home, office or outpatient facility) Other Short-Term Rehabilitative Therapies, Speech/Language3, Occupational3, Vision (Up to 60 visits per calendar year combined in home, office or outpatient facility) Cardiac Rehabilitation Second Surgical Opinion (1) A network provider must deliver al care, except in emergencies. There is no out-of-network option for this product. (2) For services received from an Empire network provider, the provider must precertify services or services may be denied. Empire's network providers cannot bil members except for copayments or coinsurance for covered services. Outside Empire's network area, you must obtain precertification from Empire's Medical Management Program for non-emergency services from in-network BlueCard® PPO providers (with the exception of MRI, MRA, PET, CAT and Nuclear Cardiology services, which do not require precertification for services rendered from in-network BlueCard® PPO providers outside of Empire's network area). (3) You are responsible for obtaining precertification from Empire's Medical Management Program for these services. Your provider may cal for you, but you wil be responsible for penalties applied if precertification is not obtained. For ambulatory surgery, precertification is required for reconstructive surgery, outpatient transplants and ophthalmological or eye-related procedures. Precertification is also required for proposed cosmetic surgery, an excluded benefit except when medical y necessary. (4) You are responsible for obtaining precertification from Empire's Behavioral Heatlhcare Management Program. Your provider may cal for you, but you wil be responsible for penalties applied if precertification is (5) Empire's network provider must obtain authorization for clinical/medical necessity for in-network services, or services may be denied; Empire network providers cannot bil members except for copayments or coinsurance for covered services. Authorization is not required for services rendered from in-network BlueCard® PPO providers outside of Empire's network area. (6) The fol owing benefits, if provided in-network for Preventive Care, are not subject to copay; mammography screenings, cervical cancer screenings, colorectal cancer screenings, prostate cancer screenings, hypercholesterolemia screenings, diabetes screenings for pregnant women, bone density testing, annual physical examinations and up to two annual obstetric and gynecological examinations. (7) The fol owing practitioners receive the lower (primary) copay for services provided in an office: Patient's PCP, obstetrics, gynecologists, certified nurse midwives, chiropractors, and physical, occupational, speech and vision therapists. The higher (specialist) copay wil apply for al other specialists when a Copay is required, and for services received in an outpatient facility for physical and other speech, language, occupational, vision and cardiac therapy. 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. Your Summary of Benefits
In-Network1
Inpatient Care3
Member Pays
Inpatient Hospital $500/$1250 per admission/maximum per calendar year per contract (As many days as is medical y necessary; semiprivate room and board) Surgery, Surgical Assistant, Anesthesia Physical Therapy, Physical Medicine or Rehabilitation $500/$1250 per admission/maximum per calendar year per contract (Up to 30 inpatient days per calendar year) Skil ed Nursing Facility $100/$250 copayment per admission/maximum per calendar year per contract (Up to 60 days per calendar year) Mental Health4
Outpatient Visits in Office or Facility $500/$1250 per admission/maximum per calendar year per contract (As many days as is medical y necessary; semiprivate room and Alcohol/Substance Abuse4
Outpatient Visits Inpatient Detoxification $500/$1250 per admission/maximum per calendar year per contract (As many days as is medical y necessary; semiprivate room and board) Inpatient Rehabilitation (Up to 30 days per calendar year) $500/$1250 per admission/maximum per calendar year per contract Medical Supplies Durable Medical Equipment3 $0 copay (benefit cap $2,000 per calendar year) Prosthetics & Orthotics3 $0 copay (benefit cap $2,000 per calendar year) Ambulance (air ambulance) Reimbursement for Gym Membership Member is reimbursed up to $600 annual y Prescription Drugs8 Retail Program – One copay required for up to a 30-day supply $100 Deductible per person per calendar year $10 copay for generic $35 copay for brand $70 copay for non-formulary Includes Contraceptives (Retail & Mail-Order) Mail-Order Program9 – Only two copays required for a 90-day The Mail-Order Program has the same copayments as the Retail Program listed above. The prescription drug plans listed, except Options 3 & 5, meet the CMS standard f or Cre ditable Coverage under the Medicare Modernization Act of 2003. To receive a 90-day supply of prescription drugs through Empire's Mail-Order Program, the prescription must be written specifical y for a 90-day supply. NOTE: This is a benefits summary only and is subject to the terms, conditions, limitations and exclusions set forth in the contract. Failure to comply with Empire's Medical Management or Behavioral Healthcare Management Program requirements could result in benefit reductions. Prism EPO Rev October 09 Prepared on 2/24/10 be 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. Your Summary of Benefits
Prism PPO
Country Life LLC
In-Network 1
Out-of-Network 2,3
Coinsurance Stop Loss $25,000/$62,500 / ($9,500/$23,750 out-of-pocket max) Lifetime Maximum Dependent Children To age 19; ful -time students to age 23 To age 19; ful -time students to age 23 Preventive Care9
Member Pays In-Network
Member Pays Out-of-Network
Adult Preventive Care Deductible and Coinsurance Annual Physical Exam Deductible and Coinsurance Deductible and Coinsurance (Up to age 19; including covered immunizations) Deductible and Coinsurance Home/Office/Outpatient Care10
Member Pays In-Network
Member Pays Out-of-Network
Home/Office Visits Deductible and Coinsurance Emergency Room/Facility (initial visit per occurrence) (Waived if admitted within 24 hours) (Waived if admitted within 24 hours) Ambulatory Surgery4/Outpatient Surgery Deductible and Coinsurance Presurgical Testing, Anesthesia Deductible and Coinsurance Chemotherapy, Radiation Therapy Deductible and Coinsurance Deductible and Coinsurance Laboratory Tests, X-rays9 Deductible and Coinsurance MRI5/MRA5, CAT Scan6, PET6 & Nuclear Cardiology6 $50 copay per service Deductible and Coinsurance Deductible and Coinsurance Chiropractic Care8 Deductible and Coinsurance Home Healthcare (Up to 200 visits per calendar year) Coinsurance (no deductible) Home Infusion Therapy Covered in-network only Hospice Care (Up to 210 days combined IP & OP per Covered in-network only Physical Therapy4 Deductible and Coinsurance (Up to 60 visits per calendar year combined in home, office or outpatient facility) Other Short-Term Rehabilitative Therapies Deductible and Coinsurance Speech/Language4, Occupational4, Vision (Up to 60 visits per calendar year combined in home, office or outpatient facility) (1) Network provider delivers care. (2) Out-of-network services (except Mental Health and Alcohol/Substance Abuse) are those from a provider that does not participate in Empire's PPO network, or with another Blue Cross and Blue Shield Plan through the BlueCard® PPO Program. (This does not apply to emergency benefits.) See (7) for Mental Health and Alcohol/Substance Abuse Services. (3) Out-of-network (O-O-N) providers – those who do not participate in Empire's PPO network, or with another Blue Cross and Blue Shield Plan through the BlueCard® PPO Program. Out-of-network providers who do not participate with Empire or with another Blue Cross and Blue Shield Plan, may balance bil over Empire's al owed amount. (4) You are responsible for obtaining precertification from Empire's Medical Management Program for these services provided in-area and out-of-area, in-network and out-of-network. Your provider may cal for you, but you wil be responsible for penalties applied if precertification is not obtained. For ambulatory surgery, precertification is required for reconstructive surgery, outpatient transplants and ophthalmological or eye-related procedures. Precertification is also required for cosmetic surgery, an excluded benefit except when medical y necessary. (5) For services received from an Empire PPO provider, the provider must precertify in-network services; Empire PPO providers cannot bil members beyond the copayment or coinsurance for covered services. Outside Empire's network area, you must obtain precertification from Empire's Medical Management Program for services from in-network BlueCard® PPO providers. You are responsible for obtaining precertification from Empire's Medical Management Program for in-area and out-of-area out-of-network services. Your provider may cal for you, but you wil be responsible for penalties applied if precertification is not obtained. (6) Empire's network provider must precertify in-network services; Empire network providers cannot bil members beyond the co-payment for covered services. Precertification is not required for out-of-network services, nor for out-of-area in- network BlueCard® PPO provider services. (7) You are responsible for obtaining precertification from the Behavioral Healthcare Manager for these services. Your provider may cal for you, but you wil be responsible for penalties applied if precertification is not obtained. (8) Empire's network provider must obtain authorization for clinical/medical necessity for in-network services; Empire network providers cannot bil members beyond the in-network copay for covered services. Authorization is not required for out- of-network services or for services rendered from in-network BlueCard® PPO providers outside of Empire's network area. (9) The fol owing benefits, if provided in-network for Preventive Care, are not subject to copay; mammography screenings, cervical cancer screenings, colorectal cancer screenings, prostate cancer screenings, hypercholesterolemia screenings, diabetes screenings for pregnant women, bone density testing, annual physical examinations and up to two annual obstetric and gynecological examinations. (10) The fol owing practitioners receive the lower (primary) copay for services provided in an office: Patient's PCP, obstetrics, gynecologists, certified nurse midwives, chiropractors, and physical, occupational, speech and vision therapists. The higher (specialist) copay wil apply for al other specialists when a Copay is required, and for services received in an outpatient facility for physical and other speech, language, occupational, vision and cardiac therapy. References continued on next page
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. Your Summary of Benefits
In-Network1
Out-of-Network 2,3
Cardiac Rehabilitation Deductible and Coinsurance Second Surgical Opinion Deductible and Coinsurance Deductible and Coinsurance Inpatient Care4
Member Pays In-Network
Member Pays Out-of-Network
Inpatient Hospital $500/$1250 per admission/maximum per calendar Deductible and Coinsurance (As many days as is medical y necessary; semiprivate year per contract Surgery, Surgical Assistant, Anesthesia Deductible and Coinsurance Physical Therapy, Physical Medicine, or Rehabilitation $500/$1250 per admission/maximum per calendar Deductible and Coinsurance (Up to 30 inpatient days per calendar year) year per contract Skil ed Nursing Facility (Up to 60 days per calendar year) $100/$250 copay per admission/maximum per Covered in-network only calendar year per contract Mental Health7
Member Pays In-Network
Member Pays Out-of-Network
Outpatient Visits in Office or Facility Deductible and Coinsurance Inpatient Care8 (As many days as is medical y necessary; $500/$1250 per admission/maximum per calendar Deductible and Coinsurance semiprivate room and board) year per contract Alcohol/Substance Abuse7
Member Pays In-Network
Member Pays Out-of-Network
Outpatient Visits Deductible and Coinsurance Inpatient Detoxification (As many days as is medical y $500/$1250 per admission/maximum per calendar Deductible and Coinsurance necessary; semiprivate room and board) year per contract Inpatient Rehabilitation(Up to 30 days per calendar year) $500/$1250 per admission/maximum per calendar Deductible and Coinsurance year per contract Member Pays In-Network
Member Pays Out-of-Network
Medical Supplies Covered in-network only Durable Medical Equipment6 $0 copay (benefit cap $2,000 per calendar year) Covered in-network only Prosthetics & Orthotics6 $0 copay (benefit cap $2,000 per calendar year) Covered in-network only Ambulance (air ambulance) Covered in-network only Reimbursement for Gym Membership Member is reimbursed up to $600 annual y Prescription Drugs11 Covered in-network only Retail Program – One copay required for up to a 30-day $100 Deductible per person per calendar year $10 copay for generic $35 copay for brand $70 copay for non-formulary Includes Contraceptives (Retail & Mail-Order) Mail-Order Program12 – Only two copays required for a The Mail-Order Program has the same copayments as the Retail Program listed above. The prescription drug plans listed, except Options 3 & 5, meetthe CMS stand ard for Creditable Coverage under the Medicare Modernization Act of 2003. To receive a 90-day supply of prescription drugs through Empire's Mail-Order Program, the prescription must be written specifical y for a 90-day supply. NOTE: This is a benefits summary only and is subject to the terms, conditions, limitations and exclusions set forth in the contract. Failure to comply with Empire's Medical Management or Behavioral Healthcare Management Program requirements could result in benefit reductions. Empire Prism PPO Rev August 09 Prepared on 2/24/10 be 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. Ancil ary 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.
Buehlers Buy Low Familymeds, Inc.
Horton and Converse Farm Fresh Pharmacy Food City-K-Va-T Food Care Drug Centers, Inc.
IHC Pharmacy Services Caremark Pharmacy IHS Infusion Services Foodarama Supermarkets Allina Community Fred Meyer Pharmacy Carrs Quality Center Inserra Supermarkets/ Allscripts Healthcare CBC Professional Solutions, Inc.
Pharmacy, Inc.
American Drug Stores, Cincinnati Group Health JH Harvey Co, LLC Associates Pharmacies American Pharmaceutical City Market Pharmacy Giant Eagle Pharmacy Coborns Incorporated Giant of Maryland American Pharmacy Community Pharmacies Kash N' Karry Food Stores Cooperative, Inc.
Costco Pharmacies Amerita, Inc.
Good Neighbor Pharmacy Appalachian Reg. Health CVS Procare Pharmacy, Grand Union Markets LLC CVS/Procare Pharmacy Gristedes Sloans, Inc.
Keystone Pharmacy Arrow Prescription Center Astrup Drug, Inc.
H.I.P. Pharmacy Service King Soopers Pharmacy Discount Drug Mart Aurora Pharmacy, Inc.
Hannaford Brothers Klingensmiths Drug Store Balls Four B Corporation Dominicks Pharmacy Harps Food Stores, Inc.
Kohll's Pharmacy & Bi-Lo Pharmacy, LLC Harris Teeter Pharmacy Hartig Drug Store Big A Drugstores, Inc.
Duluth Clinic Pharmacies Harvard Vanguard Bioscrip Pharmacy Medical Associates Lallie Supermarkets (Any Willing Provider) Harvest Foods Pharmacy Leader Drugstores Epic Pharmacy Network Brookshire Brothers, Ltd.
Healthmart Pharmacies/ Lins Supermarkets, Inc Brookshire Grocery Heartland Pharmacy Louis and Clark Drug Brown and Cole, Inc.
Family Care Network Henry Ford Health M K Stores, Inc.
Bruno's Food and Family Fare Pharmacy Major Value Pharmacy Family Pharmacy, Inc.
Hi-School Pharmacy Buehler Pharmacies Homeland Stores, Inc.
Managed Pharmacy Care * Subject to number of store locations, geography of store locations and prescription volume.
Pharmerica-Northeast Shoprite Financial Wayne Oakland Pharmacy Marshfield Clinic Pharmerica-Southeast Shoprite Pharmacy Wegman Food Market Martins Super Markets, Pharmerica-Southeast Shoprite, Inc.
Winn Dixie Pharmacy Pharmerica/Mid-Atlantic Southern Family Markets, Med-Fast Pharmacy Phoenix Area Indian Spartan Stores/The Medical College VA POC Management Group, Hospital/VA Comm Univ.
St. John Pharmacies Medicap Pharmacies St. Joseph Mercy Polks Discount Drugs Medicine Centers of PPOK/Rx Select Pharmacy Standard Drug Company Stop & Shop Pharmacy Supervalu Pharmacies, Price Cutter Pharmacy Price Wise Pharmacy Methodist Medical Group The Penn Traffic Co.
MHA LTC Network, Inc.
QOL Meds/Specialized Third Party Station Thrifty White Drug Nash Finch Company Quality Food Centers, Inc.
Navarro Discount Quality Markets Pharmacy Tops Markets, LLC Quick Chek Pharmacy Tops Pharmacy Services, Neighborcare Omnicare Raleys Drug Center Neighborcare Pharmacy Ralph's Grocery Pharmacy UCSD Medical Center Neighborcare Pharmacy Randalls Food & Drug, Inc.
Recept Pharmacies Northwest Health Revco Discount Drug Ventures, Inc.
Rinderers Drug Store United Drugs (Alaska) Rite Aid Pharmacy Oklahoma Area Indian United Supermarkets, Ltd Ronetco Stores/Shoprite Unity Retail Pharmacies/ Rushford Drug, Co.
University Medical Center of Southern Nevada Pacific Medical Clinics Safescript Pharmacies, This list is subject to change University of Missouri without prior notice.
Hospital and Clinic Park Nicollet Pharmacy University of Utah List current as of
Pathmark Pharmacy Sav-Mor Drug Stores University of Wisconsin April 2009.
Save Mart Pharmacy Upni-United Pharmacist Schnucks Pharmacy Network, Inc.
For more information Pharmacy, Inc.
Scolaris Food and Drug USA Drug and Beauty or to verify if your local Penn Traffic Company independent pharmacy is a participating provider, Sedanos Pharmacy Performance Plus Franchising, Inc.
Services provided by Empire HealthChoice Sedell's Pharmacy HMO, Inc. and/or Empire HealthChoice Serv-U Pharmacies Village Supermarkets/ Assurance, Inc., licensees of the BlueCrossand BlueShield Association, an association Pharma Card Management Sharp Rees-Stealy of independent BlueCross and BlueShield plans. The BlueCross and BlueShield names and symbols are registered marks of the Pharmacy Express Shaw's Supermarkets Wal-Mart Pharmacy BlueCross and BlueShield Association.
Serivces, Inc.
Shelly's Pharmacy Walgreens Drug Store Pharmacy Operations, Inc.
Wayne Drug Company MNYSH6542YLG RxRetailList EBCBS 7/09 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 Drugs are listed alphabetically by brand name
Apresazide (hydralazine/ Effexor (velafaxine)* A/T/S Topical Solution Apresoline (hydralazine)* Efudex (fluorouracil)* Casodex (bicalutamide)* Eldepryl (selegiline)* Arava (leflunomide)* Catapres, TTS (clonidine)* Demadex (torsemide)* Accu-Check product line Demerol (meperidine)* Elimite (permethrin)* Accutane (isotretinoin)* Demulen 28 day (ethinyl Elixophyllin (theophylline Aceon (perindopril)* Aristocort Topical Colyte (polyethylene glycol- estradiol/ethynodiol Aci-Jel Jelly (acetic acid electrolyte solution)* Elocon (mometasone)* Depakene (valproic acid)* Actigall (ursodiol)* Combipres (clonidine/ Depakote (divalproex) Empirin w/Cod (asa/codeine)* Activella 0.1-0.5 Artane (trihexyphenidyl)* Activella 1.0-0.5 (estradiol/ Depo-Provera 150mg Endal HD (phenyleph hcl/ Asendin (amoxapine)* hydrocod bit/cp)* Compazine Supp 25mg Entex PSE (guaifenesin/ (prochlorperazine supp Desowen Cream (desonide)* Acular, LS (ketorolac) Atarax (hydroxyzine HCL)* Desquam, E, X (benzoyl Epifrin (epinephrine HCl)* Ativan (lorazepam)* Adalat CC (nifedipine ER)* Desyrel (trazodone)* Adderall (amphetamine/ Condylox Solution (podofilox Eryc (erythromycin base)* (ipatropiumbromide)* Erycette 2% Pledgets Adderall XR (amphetamine/ Augmentin (amoxicillin/ Cordarone (amiodarone)* dextroamphetamine #) clavulanic acid)* Coreg (carvedilol)* Eryderm 2% Topical Solution Auralgan (antipyrine/ Diabeta (glyburide)* Erymax 2% Topical Solution Corgard (nadolol)* Diamox (acetazolamide)* Cortef (hydrocortisone)* EryPed 200 Susp (erythromycin Cortenema (hydrocortisone Esgic (acetaminophen/ Albalon (naphazoline)* Cortisporin Ophth (bacitracin Eskalith, CR (lithium)* Axid (nizatidine)* - polymyxin/neomycin- hc Estrace (estradiol)* (spironolactone/HCTZ)* Aygestin (norethindrone)* Dilacor XR (diltiazem CR)* Aldactone (spironolactone)* Cortisporin Otic (neomycin/ Dilantin (phenytoin) Aldomet (methyldopa)* Aldoril (methyldopa/HCTZ)* Azulfidine, Entabs Coumadin (warfarin) Eulexin (flutamide)* Alesse (aviane)* (sulfasalazine, EC)* Allegra (fexofenadine)* Diprolene Ointment (betamet diprop/prop gyl)* Allegra D (fexofenadine/ Bactrim DS (Sulfamethoxazole/ trimethoprim, DS)* Crolom (cromolyn sodium)* Diprosone (betamethasone Alphagan (brimonidine)* Disalcid (salsalate)* Benadryl (diphenhydramine Cyclocort (amcinonide)* Ditropan (oxybutynin)* Altace (ramipril)* Dolophine (methadone)* Bentyl (dicyclomine)* Cylert (pemoline)* Famvir (famciclovir)* Domeboro (acetic acid/ Alupent (metaproterenol)* Benzac, AC, W (benzoyl aluminum acetate)* Amaryl (glimepiride)* Donnatal (belladonna/ Fast Take Product Line Ambien (zolpidem)* Benzaclin (benxoyl peroxide/ Cytomel (liothyronine)* Amicar (aminocaproic acid)* Cytotec (misoprostol)* Dostinex (cabergoline)* Benzagel, Wash (benzoyl Cytovene (ganciclovir)* Feldene (piroxicam)* Benzamycin (benzoyl peroxide/ Dovonex soln (calcipotriene)* Amoxil (amoxicillin)* Anafranil (clomipramine)* Betagan (levobunolol)* Fibricor (fenofibric acid)* Analpram HC lotion Duragesic (fentanyl)* Duratuss G (guaifenesin SR)* Fioricet (APAP/caffeine/ (naproxen sodium, DS)* Biaxin, XL (clarithromycin, er)* Dalmane (flurazepam)* Duricef Caps/Tabs (cefadroxil)* Bicitra (sodium citrate & Danocrine (danazol)* Dantrium (dantrolene)* Dynacin (minocycline)* Fiorinal w/Codeine (butalbital Anexsia (hydrocodone/APAP)* Dynapen (dicloxacillin)* Ansaid (flurbiprofen)* Bleph-10 (sulfacetamide- sodium solution)* Flagyl (metronidazole)* Antivert (meclizine)* E.E.S. (erythromycin Brethine (terbutaline)* Anusol HC 25mg Suppositories Bumex (bumetanide)* EC-Naprosyn (naproxen EC)* Flonase (fluticasone)* (hydrocortisone)* Buspar (buspirone)* Daypro (oxaprozin)* Econopred Plus 1% Eye Drops DDAVP (desmopressin Floxin Otic (ofloxacin)* Inflamase Mild, Forte Limbitrol DS (amitriptyline/ Floxin tablet (ofloxacin)* (metronidazole lot)* Nitrol (nitroglycerin ointment)* Lioresal (baclofen)* Mevacor (lovastatin)* Nitrolingual spray Intal Solution (cromolyn)* Mexitil (mexiletine)* Lithobid (lithium)* Micro-K (potassium chloride)* Nizoral (ketoconazole)* ISMO (isosorbide mononitrate)* Lo/Ovral (low-ogestrel)* Micronase (glyburide)* Noctec (chloral hydrate)* Lodine (etodolac)* Microzide (hydrochlorothiazide Nolvadex (tamoxifen)* Folate (folic acid)* Isoptin, SR (verapamil, SR)* Lodine XL (etodolac ER)* Nor-QD (norethindrone)* Isopto Atropine (atropine Loestrin FE (microgestin 1-20, Midamor (amiloride)* Nordet e (levora)* Fosamax (alendronate)* Norflex (orphenadrine)* Lomotil (diphenoxylate/ Norgesic (orphenadrine cpd)* (pilocarpine HCl)* atropine sulfate) Minipress (prazosin)* Norgesic Forte (orphenadrine Isopto Homatropine Loniten (minoxidil)* Minocin Capsule (minocycline)* Lopid (gemfibrozil)* isosorbide dinitrate Lopressor (metoprolol)* Miralax (glycolax)* Lopressor HCT (metoprolol/ Normodyne (labetalol)* Norpace (disopyramide)* Loprox gel (ciclopirox)* Mircet e (kariva)* Mobic (meloxicam)* Norpace CR 150mg Modicon (ethinyl estradiol/ (disopyramide CR 150mg)* Norpramin (desipramine)* Garamycin (gentamicin)* K-Lor (potassium chloride Monistat-Derm (miconazole Gel-Kam Gel (stannous K-Lyte CL (potassium bicar/ Norvasc (amlodipine)* Lotensin (benazepril)* Monodox (doxycycline Novafed A (pseudo-ephedrine (benazepril HCTZ)* Monoket (isosorbide Lotrel 2.5/10, 5/10, 5/20 Glucophage (metformin)* K-Tab (potassium chloride sr)* & 10/20 (amlodipine/ Monopril (fosinopril)* Glucophage XR (metformin ER)* Motrin (ibuprofen)* Glucotrol XL (glipizide XL)* Lorel 5/40 & 10/40mg Kayexalate (sodium MS Contin (morphine SR)* Glucovance (glyburide/ polystyrene sulfonate)* Lotrisone (clotrimazole/ MSIR (morphine sulfate)* Keflex (cephalexin)* Glynase PresTab (glyburide Kenalog in Orabase Myambutol (ethambutol)* Ocufen (flurbiprofen sodium)* Loxitane (loxapine)* Ocuflox (ofloxacin)* Keppra (levetiracetam) Lozol (indapamide)* Mycolog II (nystatin/ Ocupress (carteolol hcl)* Golytely Solution (PEG– Lufyllin (dyphylline)* electrolyte for solution)* Kerlone (betaxolol)* Lupron (leuprolide)* Ogen (estropipate)* Mycostatin (nystatin)* Granulex (trypsin/balsam peru/ Klonopin (clonazepam)* Omnicef (cefdinir)* Mydriacyl (tropicamide)* Luride (sodium flouride)* Omnipen (ampicillin)* Gynodiol (estradiol)* One Touch Product Line Kytril (granisetron)* Mysoline (primidone)* Opticrom (cromolyn)* Optivar (azelastine)* Macrobid (nitrofurantoin Ortho-Cept (apri, reclipsen)* Halcion (triazolam)* Ortho-Est (estropipate)* Lamictal chewables 2mg Naldecon (decongestabs)* Lamictal chewables Marinol (dronabinol)* Nalfon 600mg (fenoprofen)* Ortho-Novum (necon)* 5 & 25mg (lamotrigine)* Materna (multi-vitamins Ortho Tri-Cyclen (tri-nessa)* Histussin HC (phenyleph/ Lamictal tabs (lamotrigine) Naprosyn (naproxen)* Lamisil tablet (terbinafine)* Ortho Tri-Cyclen Lo Orudis (ketoprofen)* Mavik (trandolapril)* Nasarel (flunisolide)* Oruvail (ketoprofen SA)* Natafort (prenatal vitamin)* Ovral (ogestrel)* Lariam (mefloquine)* Natalins (prenatal multivitamins OxyContin (oxycodone ER) Humibid LA (guaifenesin)* Lasix (furosemide)* and minerals/iron/fa)* Humulin R, N, 50/50, 70/30 Navane (thiothixene)* Hycodan Syrup (hydrocodone Mebaral (mephobarbital)* Hydrea (hydroxyurea)* Pamelor (nortriptyline)* NeoDecadron (neomycin/ Hytone (hydrocortisone 2.5% Levbid (hyoscyamine)* Panoxyl, AQ (benzoyl peroxide)* cream, ointment, lotion)* Medrol 2 mg, 16mg, 32mg Parafon Forte (chlorzoxazone)* Hytrin (terazosin)* Levlen (levonorgestrel & ethinyl Megace (megestrol)* Neosporin soln (neomycin/ Mellaril (thioridazine)* Levo-Dromoran (levorphanol Parlodel Tab (bromocriptine)* Neosporin oint (neomycin/ Ilotycin (erythromycin)* Paxil (paroxetine)* Imdur (isosorbide Mestinon timespan Levsin (hyoscyamine)* Paxil CR (paroxetine SR)* Neurontin (gabapentin)* Imitrex (sumatriptan)* Levsinex (hyoscyamine)* Pediapred (prednisolone sodium prosphate)* Imodium (loperamide)* Pediazole (erythromycin/ Imuran (azathioprine)* Inderal (propranolol)* Niferex-150 Forte (iron/B12/ Pentam (pentamidine Inderal LA (propranolol la)* Lidex, E (fluocinonide)* MetroGel Vaginal Indocin, SR (indomethacin, SR)* (metronidazole vag)* Nitro-Bid (nitroglycerin SR)* Pepcid (famotidine)* Procardia (nifedipine)* Robaxin (methocarbamol)* Tussionex Pennkinetic ER Procardia XL (nifedipine ER)* Rocaltrol (calcitriol 0.25, 0.5 Tagamet (cimetidine)* Peridex (chlorhexidine Proctocream-HC (hemorhoidal Talwin NX (pentazocine nx)* Tylox (oxycodone Periostat (doxycycline)* Profasi 10,000 (chorionic Tambocor (flecainide)* Rondec, TR (pseudoephedrine/ Tavist syrup, 2.68mg tabs Phenergan DM (promethazine/ Prograf (tacrolimus) (clemastine fumarate)* Roxicodone (oxycodone)* Phenergan VC syrup Tegretol (carbamazepine) Rynatuss tablets, pediatric Phenergan/Codeine susp (phenyleph- ephed-cpd (carbamazepine ER) (procainamide, SR)* Ultram, ER (tramadol)* Propine (dipivefrin HCl)* Rythmol (propafenone)* Ultrase (pancrelipase) Phenergan VC/Codeine Temovate (clobetasol)* Ultravate (halobetasol)* Proscar (finasteride)* Tenex (guanfacine)* Tenoretic (atenolol/ (theophylline SR) Salagen (pilocarpine)* Phoslo (calcium acetate)* Proventil, Tab, Syrup Tenormin (atenolol)* Pilocar (pilocarpine HCl)* Sandostatin (octreotide Terazol (terconazole)* Provera (medroxy- Univasc (moexipril)* Seasonale (jolessa, quasense)* Plan B 0.75mg (levonorgestrel)* Prozac (fluoxetine)* Sectral (acebutolol)* Tessalon Perles (benzonatate)* Psorcon (diflorasone Selsun (selenium sulfide)* Urised (meth/salicylate/ Septra, DS (sulfamethoxazole/ atropine/hyos benzoic)* Pulmicort Respules trimethoprim, DS)* Urocit-K (potassium citrate)* Pulmicort Turbuhaler Serax (oxazepam)* Urogesic Blue (methenamine/ Plexion TS (sulfacet sod w/ (chlorpromazine tab)* hyosc-meth blue/sod biphos- Serophene (clomiphene)* Ticlid (ticlopidine)* Poly-Vi-Flor (multi-vitamins w/ Silvadene (silver sulfadiazine)* Polycitra (potassium citrate- Timoptic XE (timolol)* Polycitra-K (Pot. & Sod. Citrates Sinemet CR (carbidopa/ V-Cillin K (penicillin V.K.)* Questran, Lite (cholestyramine, Polysporin (bacitracin zinc/ Sinequan (doxepin)* Tobradex oint.
Quinaglute (quinidine Tobradex susp. (tobramycin/ Valisone (betamethasone Polytrim (polymyxin B/ Quinidex (quinidine sulfate)* Slo-Bid (theophylline)* Tobrex Soln (tobramycin)* Valium (diazepam)* Potaba Tab (aminobenzoate Tofranil (imipramine)* Slo-Phyllin 80 Syrup Tolectin (tolmetin)* Valtrex (valacyclovir) potassium chloride Vantin (cefpodoxime)* Sodium Sulamyd (sulfacetamide Topamax Pramosone 1% cream only, Vaseretic (enalapril/ (galantamine, sr)* Solaquin Forte (hydroquinone)* Vasocidin (sulfacetamide Rebetol (ribavirin)* Soma (carisoprodol)* Toprol XL (metoprolol)* sodium-prednisolone Pravachol (pravastatin)* Reglan (metoclopramide)* Toradol (ketorolac Precose (acarbose)* Relafen (nabumetone)* Vasocon (naphazoline)* Pred Forte 1% (prednisolone)* Remeron, SolTab (mirtazapine)* Sonata (zaleplon)* Trandate (labetalol)* Vasotec (enalapril)* Sorbitrate (isosorbide Tranxene (clorazepate)* Vepesid (etoposide)* Prelone (prednisolone)* Requip* (ropinirole) Spectazole (econazole)* Premarin oral, vaginal cream Verelan (verapamil SR)* Sporanox (itraconazole)* Tricor (fenofibrate)* Vermox (mebendazole)* Restoril (temazepam)* Stadol N.S. (butorphanol TriLeven (levo norgestrel)* Retin-A Cream (tretinoin)* tartrate 10 mg/ml N.S.)* Tri-Vi-Flor (triple vitamins (prenatal w/docusate, Starlix (nateglinide) iron, folic acid)* Retin-A Gel (tretinoin)* Tridesilon (desonide)* Trilafon (perphenazine)* Vicodin E.S. (hydrocodone/ Prenate Ultra (multi-vitamins w/ Revia (naltrexone hcl)* Subutex (buprenorphine)* Prevacid (lansoprazole)* Sular 20, 30 & 40mg Trimox (amoxicillin)* Videx EC (didanosine)* Prevident (sodium fluoride)* Rheumatrex Tablets Trimpex (trimethoprim)* (methotrexate tablets)* Sular 8.5, 17, 25.5 & 34mg Trinsicon (iron/intrinsic factor/ Sulfacet-R (sodium Prilosec (omeprazole)* Rifadin (rifampin)* Triphasil (trivora)* Sultrin (triple sulfa)* Prinivil (lisinopril)* Trusopt (dorzolamide)* Vistaril (hydroxyzine pamoate)* Risperdal (risperidone)* ProAmatine (midodrine)* Tussi-Organidin NR Risperdal ODT, M-tab Symmetrel (amantadine)* Synalar (fluocinolone Tussi-Organidin NR Ritalin, SR (methylphenidate, (diclofenac sodium)* RMS Supp (morphine)* Voltaren, XR (diclofenac, ER)* Vosol (acetic acid)* Xanax (alprazolam)* Zanaflex (tizanidine)* Zetacet (sulfacetsod w/sulfur Zovirax Cap (acyclovir)* Vosol HC (acetic acid/ Xopenex Neb Soln Zantac (ranitidine)* Zarontin (ethosuximide)* Ziac (bisoprolol/HCTZ)* Xylocaine (lidocaine)* Zaroxolyn (metolazone)* Zyloprim (allopurinol)* Xylocaine viscous (lidocaine viscous)* Zebeta (bisoprolol)* Zenate (multi-vitamins Zocor (simvastatin)* Zofran (ondansetron)* Wellbutrin, SR (bupropion)* Zephrex LA (pseudo- Zoloft (sertraline)* Zerit (stavudine)* Zestril (lisinopril)* Yocon (yohimbine)* 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)*
Sporanox (itraconazole)* Lamisil tablet (terbinafine)* QUANTITY LIMIT: affects the frequency or dosage of certain medications for which you receive benefits.
Aciphex*
Actiq (fentanyl citrate)* Allegra (fexofenadine)* Optivar (azelastine)* Sonata (zaleplon)* Allegra D (fexofenadine/ Imitrex (sumatriptan)* Stadol N.S. (butorphanol)* Ambien (zolpidem)* Diabetic Test Strips Kytril (granisetron)* Prevacid (lansoprazole)* (Accu-Chek and One Touch brand products are formulary) Lunesta* Prilosec (omeprazole)* Nasarel (flunisolide)* (pantoprazole# )* Zofran (ondansetron)* Flonase (fluticasone)* STEP THERAPY: requires that you first use a specific medication before alternatives therapies may be tried or prescribed.
Adderall (amphetamine/
dextroamphetamine #) (pantoprazole# )* Nasarel (flunisolide)* Diabetic Test Strips (Accu- Chek and One Touch brand Sonata (zaleplon)* products are formulary) 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.
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
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 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 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. This is a brief overview of your plan's features. Your evidence of coverage or medical policy contains the details. See your benefits manager if you need a copy. Thank you for considering Empire.
MNYSH6540Y RxBenefits 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
w w w Identi icatignwFmmbej wwwwwwwwwwInitialw Datewg wbijthw(MM/ DD/ YYYY) 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.
w wStatewwwwwwwwRIHwcg ew wwDaytimewhhgneww incdmdin_wajeYwcg e)w wwEvenin_whhgneww incdm in_wYjeYwcg e) 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
OvejnighlwKhippin_w Y dw*() Amgmnlwencdgse 2w 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.
wwwwwwwwwInitialwwwwwwHatienlw Ytewg wZijthw(MM/ DD/ YYYY!wwwwHatienlw_endej @ighwbdgg whjessmjeww Othejw dislwYdd!w wTakenwZ] gjewwwwww (will order when needed) Language translation services available at 877-373-6770. NextRx, PO Box 746000, Cincinnati, OH 45274-6000 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.
Empire Blue View VisionSM
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:
1. Go to empireblue.com 2. Select "Blue View Vision" 3. Enter your search criteria 4. Click "View Results" 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.
WELCOME TO
Blue View VisionSM BLUE VIEW VISION!
Good news—your vision plan is
Basic Eye Care & Eyewear Discounts flexible and easy to use. This benefit summary outlines the basic Your Blue View Vision network
components of your plan, including Blue View Vision offers you one of the largest vision care networks in the industry, with a wide selection of experienced quick answers about what's covered, ophthalmologists, optometrists, and opticians. Blue View Vision's network also includes convenient retail locations, many your discounts, and much more! with evening and weekend hours, including LensCrafters®, Target Optical®, JCPenney® Optical, Sears OpticalSM, Pearle Vision®, and New York based Empire Vision and Davis Vision Centers.

Best of al – when you choose to receive care from a Blue View Vision participating provider, you receive ful in-network
benefits and money-saving discounts.
Out-of-network services
Did we mention that we're flexible? We offer you the option to receive care outside of the Blue View Vision network. If
you choose an out-of-network provider, you wil receive an al owance toward an eye exam and you pay the rest. Network
benefits and discounts wil not apply. When you receive eye care from a non-participating provider, you wil pay in ful at
the time of service then file a claim for reimbursement to Blue View Vision, Attn: OON Claims, PO BOX 8504, Mason, OH
45040-7111.
For questions about your vision benefits, contact Blue View Vision customer service at 866-723-0515.
YOUR BLUE VIEW VISION PLAN AT-A-GLANCE:
VISION CARE SERVICES
IN-NETWORK
Routine eye exam (once every 12 months)
DISCOUNTS
Please check with your participating Blue View Vision eye care professional or vision center for valuable discounts on eyewear materials.*
* Blue View Vision offers money saving discounts through our Additional Savings Program. Please ask your sales representative or in-network provider for further details.
USING YOUR BLUE VIEW VISION PLAN
The Blue View Vision network is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care physician from your medical
network.
EXCLUSIONS & LIMITATIONS
This is a primary vision care benefit and is intended to cover only eye examinations. Any items not covered below may be purchased at preferred pricing from a Blue View Vision
provider. In addition, exam benefits are payable only for expenses incurred while the group and insured person's coverage is in force.
Combined Offers. Services or supplies combined with any other offer, coupon or in-store
Sunglasses. Sunglasses and accompanying frames.
Safety Glasses. Safety glasses and accompanying frames.
Experimental or Investigative. Any services that are experimental or investigative or related to such,
Hospital Care. No benefits are provided for services received in a government or a public benefit
whether incurred prior to, in connection with, or subsequent to the experimental or investigative corporation Hospital unless we have a participation agreement or special agreement with that services or supply, as determined by us, or that are received from a vision or medical department Hospital (and then only for the specific services to which the special agreement applies). maintained by or on behalf of an employer, mutual benefit association, labor union, trust or similar person or group.
Orthoptics. Treatment of eye disease or injury, additional diagnostic testing and special
procedures such as orthoptics training are not covered under this Certificate. Crime or War. Conditions that result from: (1) For a condition resulting from participation in a felony,
riot or insurrection; or (2) for il ness or injury that occurs as a result of any act of war, declared or
Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or
undeclared, or any act of war. lenses that have no refractive power. Bifocals. Two pair of glasses in lieu of bifocals.
Uninsured. Services received before insured person's effective date or after coverage ends.
Lost or Broken Lenses or Frames. Replacement of lost, stolen, broken or duplicate frames or
Excess Amounts. We wil not pay an amount that is more than a Vision Care Provider charged for
Covered Vision Services nor that is more than the customary charges, nor wil we credit such an amount toward the Copayment. Voluntary Payment. We wil not cover any service if it is usual y provided without charge.
Routine Exams or Tests. Routine examinations required by an employer in connection with insured
Missed appointments. We wil not reimburse the cost associated with a missed or canceled
person's employment. Work-Related. For any condition, disease, defect, aliment, or injury arising out of or in the course of
Services of Relatives. For services or supplies prescribed, ordered, referred by, or received from
employment if benefits are available under any Worker's Compensation Act or other similar law. This a member of your immediate family, including your spouse, child, brother, sister, parent, in-law, exclusion applies if you received the benefits in whole or in part. This exclusion also applies whether grandparent or self. or not you claim the benefits or compensation. It also applies whether or not you recover from any Preexisting. Conditions or diseases.
Armed forces. For services or supplies related to service in the Armed Forces or units auxiliary
Government Treatment. To the extent that they are provided as benefits by any governmental unit,
unless otherwise required by law or regulation. Eyewear. Eyeglass lenses, frames and contact lenses.
The in-network providers referred to in this communication are independently contracted providers who exercise independent professional judgment. They are not agents or employees of Anthem. This benefit overview insert is only one piece of your entire enrol ment package. Exclusions and limitations are listed in the enrol ment brochure. 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 7 r e registered marks of the Blue Cross and Blue Shield Association. 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) FAX to: 1-800-780-1224Mail to: Empire PO Box 1407 Church Street StationNew 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:
4. Is dependent employed?
5. List any other group insurance or pre-payment program the dependent is covered under:
6. Is the dependent a student
7. School name and address:
8. Type of school (college, trade, etc.)
9. Expected date of:
Course Completion: 10. Was the dependent a full-time student at an accredited school who is now on a leave of absence from
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 I understand that any person who knowingly and with intent to defraud any insurance company or other person files anapplication for insurance or statement of claim containing any materially false information, or conceals, for the purpose ofmisleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shallalso 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.
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: 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. J e Z j kXXpl[X e jgXŒfcgXiX ek e[ i jk [fZld ekf"gl [ jfc Z kXicXj eZfjkfX[ Z feXc"ccXdXe[fXce’d if[ j im Z fXcZc ek hl XgXi Z Xc[fijf[ jlkXia kX[  [ ek ] ZXZ ef e c]fcc kf[  ejZi gZ e% 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 Important legal information you should
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:
J e[ljXni kk ei hl jkkfj fi kXZfgpf]Z ikX e[email protected]fiXjbk_Xkn Zfii Zkpfli[email protected]k_XkpflY c m  jd jj e fi eZfii Zk%@]jfd fe  cj jlZ_Xjpfli[fZkfi Xm ljk_ [email protected]"n n ccc kpflbefnjfpflZXeXjbk_ dkfZfii Zk k% J e[ljXni kk ei hl jkkfXjbljefkkflj pfli[email protected]]fiki Xkd ek"gXpd ekfi_ Xck_ZXi fg iXk fejXZk m k j%N Xi efki hl i [kfX i kfk_ j i hl jkj% > m ljXm iYXcfini kk ei hl jkkfXjbljkfj e[pfli[email protected]lj e fk_ id Xejk_XkXi i XjfeXYc %8cjfc kljbefn ]pflnXekljkfj e[pfli[email protected]kfXeX[[i jjfk_ ik_Xepfli_fd  ]j e[ e  kkfpfli_fd Zflc[gcXZ pfl e[Xe i% J e[ljXni kk ei hl jkkfXjblj]fiXc jkf]Z ikX e[ jZcfjli jf]pfli[email protected]% MNYSH6554Y HIPAA-WHCRA Important legal information you should
take time to read (continued)

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.
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.
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.
MNYSH6554Y HIPAA-WHCRA Important legal information you should
take time to read (continued)

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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J e Z j kXXpl[X e jgXŒfcgXiX ek e[ i jk [fZld ekf"gl [ jfc Z kXicXj eZfjkfX[ Z feXc"ccXdXe[fXce’d if[ j im Z fXcZc ek hl XgXi Z Xc[fijf[ jlkXia kX[  [ ek ] ZXZ ef e c]fcc kf[  ejZi gZ e% MNYSH6554Y HIPAA-WHCRA 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.
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 Thank you for choosing Empire. Please fill out all items in order for us to quickly and accurately process your enrollment. Once you've completed this form, please sign in the space provided in Section 7.
1. REASON FOR ENROLLMENT/CHANGE (COMPLETE SECTION A, B OR C)
A. NEW ENROLLMENT/ADDITION (FILL IN ONE BOX ONLY)
m New hire (Proof of employment is necessary for applicants in companies with 50 or fewer employees.
Date of change (MMDDYY) Please submit NYS-45, payroll records or W-4 forms to establish employment.) m Open enrollment
m Status change (fill in one box)
m Marriage m Newborn m Medicare eligible (answer questions below) (fill in one box only) m End stage renal disease Electing company coverage as primary coverage? Electing Medicare-related coverage as primary coverage? (If company size is under 20 employees and end stage renal disease does not apply, you must choose this option) m Part-time to Full-time
m COBRA/NYS Continuation of coverage
Nature of COBRA/NYS event B. CHANGE (FILL IN ALL BOXES THAT APPLY)
For all boxes filled in below, please supply new information in Section 3.
m Name m Primary Care Physician (PCP) m Managed Dental Primary Care Dentist (PCD) (HMO/Direct HMO/POS/DSPOS plans only) (If your company offers an Empire Dental plan) C. CANCEL COVERAGE (FILL IN ONE BOX ONLY)
Note: If you are canceling your own coverage, please have your employer fill out an Employee Termination Form. For other cancellations, please fill in the appropriate box below and enter the name in the Spouse/Dependent portion in Section 3.
m Dependent no longer eligible Date of event (MMDDYY) 2. BENEFITS SELECTION
Medical Insurance1 (fill in one box only)
m Direct HMO m EPO (large group only) m Value EPO (small group only) m Empire Total BlueSM Choice (HSA) m Empire Total BlueSM Choice (HRA) m Empire PrismSM PPO (large group only) m Empire PrismSM EPO m Hospital/Medical or m Hospital Only
Coverage type (fill in one box only) m Individual m Employee/Spouse m Parent/Child(ren) Dental Insurance2 (fill in one box only)
m PPO Dental m Managed Dental m Voluntary Dental Coverage type (fill in one box only) m Individual m Employee/Spouse m Parent/Child(ren) Vision Insurance3 Blue View VisionSM
Coverage type (fill in one box only)
m Individual m Employee/Spouse m Parent/Child(ren) 1 Empire will facilitate the opening of a Health Savings Account in your name, as directed by your Employer.
2 If your company offers an Empire Dental Plan.
3 If your company offers a Blue View Vision plan.
ENR0296B Rev. 8/09 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.
3. APPLICANT AND SPOUSE/DOMESTIC PARTNER/DEPENDENT INFORMATION
Note: If you've chosen HMO/Direct HMO/POS/DSPOS, please provide a primary care physician (PCP) for yourself and for each dependent. Please note that no out-of-network benefits are available to HMO/Direct HMO members except for emergency care. If you've chosen Managed Dental, please provide one Primary Care Dentist (PCD) for you and your dependents.
Social Security no.
Birthdate (MMDDYY) Date of marriage (MMDDYY) m Married m Single Place of marriage* Current patient of PCP?m Yes m No Primary Care Dentist (PCD) Last name Current patient of PCD?m Yes m No Last name (if different) Social Security no.
Birthdate (MMDDYY) Primary language (if different) m Male m FemalePCP Last name Current patient of PCP?m Yes m No DEPENDENT 1
Last name (if different) Social Security no.
Birthdate (MMDDYY) Primary language (if different) m Male m FemalePCP Last name Current patient of PCP?m Yes m No m Disabled child*** DEPENDENT 2
Last name (if different) Social Security no.
Birthdate (MMDDYY) Primary language (if different) m Male m FemalePCP Last name Current patient of PCP?m Yes m No m Disabled child*** 52 DEPENDENT 3
Last name (if different) Social Security no.
Birthdate (MMDDYY) Primary language (if different) m Male m FemalePCP Last name Current patient of PCP?m Yes m No m Disabled child*** ***Marriage must have been entered into in a jurisdiction that recognizes its validity.****Must be age 19+ and attend accredited college or university. Submit proof with this form. Proof is required annually.
***Please submit Request for Disabled Child form (HAC506) with this form; child must be age 19+.
4. OTHER COVERAGE INFORMATION
Do you currently have or have you had health insurance in the past 11 months? m No (if no continue to Spouse/Dependent(s) section below)
Has the coverage been continuous during the past 11 months? Coverage start date (MMDDYY) Will your current group insurance remain in effect after you enroll in this Empire plan? m Yes Coverage end date (MMDDYY) Name of other insurance carrier Your ID no. from other carrier Coverage provided by employer? Employment status m Active m Employee/Spouse m Hospital only m Hospital/Medical m Medical only m Parent/Child(ren) Does your spouse/dependent(s) currently have or have they had health insurance in the past 11 months? m Yes m No (if no continue to section 5)
Has the coverage been continuous during the past 11 months? Coverage start date (MMDDYY) Will their current group insurance remain in effect after you enroll in this Empire plan?m Yes Coverage end date (MMDDYY) m My spouse has or has had the same coverage as I. Note: You do not need to fill out the rest of the spousal other coverage questions. m My dependents have or have had the same coverage as I. Note: You do not need to fill out the rest of the dependent other coverage questions. Name of Spouse's other insurance carrier Coverage start date (MMDDYY) Coverage end date (MMDDYY) Coverage provided by employer? Employment status m Active m Employee/Spouse m Hospital only m Hospital/Medical m Medical only m Parent/Child(ren) DEPENDENT 1
Name of dependent's other insurance carrier Coverage start date (MMDDYY) Coverage end date (MMDDYY) Coverage provided by employer? Employment status m Active m Employee/Spouse m Hospital only m Hospital/Medical m Medical only m Parent/Child(ren) DEPENDENT 2
Name of dependent's other insurance carrier Coverage start date (MMDDYY) Coverage end date (MMDDYY) Coverage provided by employer? Employment status m Active m Employee/Spouse m Hospital only m Hospital/Medical m Medical only m Parent/Child(ren) DEPENDENT 3
Name of dependent's other insurance carrier Coverage start date (MMDDYY) Coverage end date (MMDDYY) Coverage provided by employer? Employment status m Active m Employee/Spouse m Hospital only m Hospital/Medical m Medical only m Parent/Child(ren) 5. MEDICARE INFORMATION (FOR MEDICARE ELIGIBLE ONLY.)
Please provide a copy of your Medicare (HIB) card. If a copy is not attached, we cannot process your Medicare benefits request.
I understand that if I become Medicare eligible while I am covered under this contract, any benefits I am entitled to under this contract will be reduced by any amounts paid by Medicare for those services, whether or not I apply for or submit a claim to Medicare.
Applicant last name Medicare ID no.
Part A Coverage start date (MMDDYY) Part B Medical Coverage start date (MMDDYY) Spouse/Dependent's last name (if different) Medicare ID no.
Part A Coverage start date (MMDDYY) Part B Medical Coverage start date (MMDDYY) 6. EMPLOYER INFORMATION (THIS SECTION MUST BE FILLED IN BY YOUR GROUP BENEFITS ADMINISTRATOR.)
Group Sub no.
Employee no.
Applicant's start date of full-time employment (MMDDYY) 7. APPLICANT SIGNATURE (I HAVE READ THE CERTIFICATION AND FRAUD STATEMENT BELOW.)
I certify that I am electing coverage as an employee, or former employee, retiree, current or former dependent of an active employee, or retiree, and am eligible for group coverage under the terms and conditions of the group's contract. I make this election on behalf of all eligible dependents and myself. I understand that I am under a continuing obligation to notify the group of a change in my, or my dependent's, status; such change may result in a change of insurance status with Empire and that failure to make such notification may result in cancellation of the coverage by Empire. Any other Empire coverage will end upon issuance of this coverage. If I do not agree to transfer my other coverage with Empire to this coverage, I understand that this application will not be accepted by Empire.
I authorize any health care provider, health care payor or government agency to furnish to Empire or its designee all records pertaining to medical history, services rendered, and payments made regarding me or my dependents for use by Empire to administer the terms of my health benefits contract. I also authorize Empire to disclose such information to an Empire designee, my PCP and other providers, other payors, and the group contract holder, for purposes of continuity of care and medical management, disease management, health benefits contract administration, financial audits, and as otherwise required by law. All statements and answers in this notice of election are true and are representations made to induce the issuance of the coverage. Any material misrepresentation may result in Empire's cancellation of coverage.
Insurance Fraud Statement: Any person who knowingly and with intent to defraud an 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 material fact there to, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim or each such violation.
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Source: http://personalorder.countrylifevitamins.com/shared/hr/forms/openEnrollment/blueCrossEnrollmentBookEnglish.pdf

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Alzheimer's Disease Information Network ADIN Monthly E-News For more informa- tion on clinical trials, visit the ADEAR Clinical Trials Website Alzheimer's Disease Cooperative Study March 2016 _ Can Common Heartburn Drugs Raise Dementia Risk?

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