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GHI CBP Program for City of New York Employees and Retirees

We want to make the health insurance process as convenient as possible for you. The GHI-CBP basic plan comes with these features:

• Broad benefits, which apply even if you're traveling.
• No referrals or approvals needed for specialist care.
• No claim forms to file when you receive services in-network.
• Responsive customer service.

Here is a summary of the benefits you receive when you choose GHI:

• Office and home visits *
• Diagnostic X-ray and laboratory examinations, subject to $15 copayment per visit *
• Well-baby and well-child care and immunizations, for children up to age 19
• Physical and speech therapy *
• Non-routine podiatric care *
• Surgery, surgical assistants and anesthesia administration
• Intensive-care visits
• Chiropractic care *
• Specialist consultations and radiation therapy
• Visiting Nurse Services
• Maternity-care coverage
• Ambulance, covered at 80% of GHI's allowed charge.
• Mammography and pap-smear screenings
• Private-Duty Nursing, covered in full when using a GHI Participating Provider. Annual Basic Plan Maximum: $100,000.
• Allergy care *
• Outpatient mental health treatment
• Durable Medical Equipment, paid-in-full when obtained through a GHI Preferred Provider. $100 annual deductible per person. Precertification required for items over $2,000.
• Coverage for Non-Mandated In-Vitro Fertilization Services
  A 25% coinsurance will apply to following non-mandated In-Vitro Fertilization services:
  CPT4

  Procedure

   
  58970

  Follicular puncture oocyte retrieval

   
  58974

  Embryo transfer

   
  58976

  GIFT/ZIFT

   
  76948

  US guidance for aspiration of ova

   
  89250

  Culture and fertilization

   
  89251

  Culture and fertilization with co-culture of embryo

   
  89252

  ICSI

   
  89253

  Assisted hatching

   
  89254

  Oocyte ID

   
  89255

  Preparation of embryo for transfer

   
  89256

  Preparation of embryo for transfer including thaw

   
  89257

  Sperm ID from aspirate other than seminal fluid

   
  89258

  Cryopreservation of embryos

   
   
  The coinsurance applies to services rendered by GHI participating and non-participating providers. Additionally, services rendered by non-participating providers are subject to the non-participating provider deductible.

*GHI participating medical providers/practitioners and participating mental health care providers will require a $15 copayment per visit. These include providers who practice:

GHI participating Surgeons, all Surgical Subspecialties, and Dermatologists will require a $20 copayment per visit. These include providers who practice: Cardiothoracic and Thoracic Surgery; Colon and Rectal Surgery; General Surgery; Neurological Surgery; Ophthalmology; Oral Surgery; Orthopaedic and Hand Surgery; Otolaryngology; Plastic Surgery; Podiatry and Podiatric Surgery; Traumatic Surgery; Urology; Vascular and Veno Surgery.

Note: Benefits for covered services rendered by non-participating providers is subject to $200 per person/$500 per family per calendar year deductible. Reimbursement is based on the City of New York Non-Participating Provider Schedule.

• 365 days semi-private room and board per calendar year ($300 deductible per admission, $750 maximum deductible per person per calendar year).**
• Routine nursery care and initial in-hospital pediatric visit for newborns.
• Inpatient detoxification and rehabilitation for chemical dependency
• Administration of anesthesia
• Intensive care**
• Hospice care in a state-certified facility**
• Pre-surgical testing**
• Outpatient chemical dependency rehabilitation
• Blood and related services, supplies and equipment*
• Inpatient mental health treatment
• Chemotherapy
• Dialysis for kidney failure**
• Emergency care, subject to a $50 per visit copayment (waived if admitted)**
• Outpatient surgery**
• Premature infant care**
• In-hospital medical visits
• Home care, including paid-in-full network benefits through GHI's Home Care Services Benefits Program. Home infusion therapy, private-duty nursing, outpatient chemotherapy, and other nursing services included.
• Enhanced Mental Health and Chemical Dependency benefits available through a comprehensive network of quality practitioners and facilities. Benefits include a 24-hour toll-free Clinical Referral Line for crisis intervention, network referrals, or telephone assessments.

**Coverage provided by Empire Blue Cross and Blue Shield.

The GHI-CBP Optional Rider provides valuable additional benefits. If you need prescription drug coverage, the Optional Rider covers brand, generic, retail and easy-to-use mail-order benefits.

Prescription Drug
Retail pharmacy up to a 30-day supply (two fills) subject to deductible of $150 per individual/$450 per family. After deductible, you pay:

• Generic — 20% coinsurance with a minimum charge of $5 or actual cost if less;
• Brand Name Formulary — 40% coinsurance with minimum charge of $25 or actual cost if less;
• Brand Name Non-Formulary — 50% coinsurance with minimum charge of $40 or actual cost if less.
If you choose a formulary or non-formulary brand that has a generic equivalent, you will pay the difference in cost between the drug and the generic coinsurance.

Mandatory Maintenance Mail Order
Up to a 60-day supply. You pay: $10 Generic/$40 Brand-Name Formulary/$60 Brand-Name Non-Formulary. You must use Mail Service for medications. Prescriptions will not be filled at retail after two (2) fills.

Prior Authorization
Prior authorization is required for certain brand-name medications.

Step-therapy Prescription Program
This program encourages use of best medications for you condition.

Over-the-Counter Equivalent Program (OTC)
Prescription medications that have an OTC equivalent will not be covered.

You'll also receive:

• Enhanced mental health and chemical dependency services.
• An enhanced reimbursement schedule for certain surgical and in-hospital services when you use non-participating providers.
• An increase in Annual Maximum from $100,000 to $200,000 for Private-Duty Nursing.

Hospital Benefits (Empire BlueCross BlueShield)
The hospital inpatient deductible will change to $300 per admission, with a maximum of $750 per person, per calendar year.

Medical Benefits (GHI)
After you have satisfied the Medicare Part B deductible, you will be responsible for an additional $50 of covered Senior Care services per individual, per calendar year. GHI then pays the Medicare Part B coinsurance (that is, 20% of Medicare Allowed Charges) for covered services for that calendar year.

Please note that the separate $25 calendar year deductible for private duty nursing, ambulance, and durable medical equipment will remain unchanged.

The City of New York Enhanced Part D program is available to City of New York retirees who also enroll in the City of New York GHI Senior Care program. The City of New York Enhanced Medicare Part D program is a Medicare drug plan and is in addition to your coverage under Medicare; therefore, you will need to keep your Medicare coverage. You can only be in one Medicare prescription drug plan at a time. For more details, click on the link below to download the Summary of Benefits and Prescription Drug Plan brochure.

• City of New York/GHI Enhanced Medicare Part D Prescription Drug Plan Summary of Benefits Brochure
• Prior Authorization Criteria
• Step Therapy Criteria
• City of NY CNY Enhanced Medicare Part D Prescription Drug Plan 2009 Cover Letter
• Express Scripts Claim Form
• City of New York Medicare Part D Prescription Drug Program 2009 National Formulary
• Medicare Part D Formulary Change, Effective 11/01/2009
• Medicare Part D Formulary Change, Effective 10/01/2009
• Medicare Part D Formulary Change, Effective 08/01/2009
• Medicare Part D Formulary Change, Effective 07/01/2009
• Medicare Part D Formulary Change, Effective 06/01/2009
• Medicare Part D Formulary Change, Effective 05/01/2009
• Medicare Part D Formulary Change, Effective 04/01/2009
• Medicare Part D Formulary Change, Effective 03/01/2009

Coverage for Psychotropic, Injectable, Chemotherapy and Asthma Medications
For Non-Medicare eligible employees retirees and their dependents, pharmacy benefits for Chemotherapy and Injectable Medications are provided under the City of New York PICA Program and pharmacy benefits for Psychotropic and Asthma medication are provided under the GHI Optional Rider Program. The City of New York PICA Program is administered by NPA, a division of Express-Scripts, Inc. (ESI). If you have questions regarding the PICA program, you should call ESI at 1-800 467-2006.

Coverage for Cancer Second Opinions
Coverage is provided for second opinions for eligible members who have been diagnosed with cancer. Members may visit any appropriate specialist for the second opinion.

Coverage for Breast Reconstructive Surgery
Coverage for breast reconstructive surgery following a mastectomy, including breast reconstruction on a healthy breast required to achieve reasonable symmetry, is provided.

Diagnosis Specific Programs
Arthritis, Depression, Diabetes and Osteoporosis

GHIAnswerLine and GHI.com

Besides working hard to continue to offer you the highest level of care, we also continually look for new ways to make our administrative process easier for you. Our 24-hour automated telephone-response system, AnswerLine 212-501-4GHI, and this Web site are available to all GHI members. You can use them to find a GHI Participating Provider, order claim forms, and find out other important information about your coverage. Available at your convenience, these services provide fast, accurate information whenever you need it.

If you have any questions or you would like to know more about GHI, please call us at212-501-4GHI (4444).

This is a summary of the features of the GHI Comprehensive Benefits Plan available to you as a City of New York employee or retiree. The full terms and conditions governing your health plan are set forth in the Group Contract as amended between GHI and the City of New York and in the Certificate of Insurance.