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GHI CBP Program for City of New York Employees, Retirees and GHI Standard and Enhanced Medicare Part D Prescription Drug Plans

We want to make the health insurance process as easy as possible. You can get the hospital, medical and prescription drug coverage you need from our plans. There are no referrals or approvals needed for specialist care and no claim forms to file when you get services in-network.

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

• Office and home visits* (specialists**)
• Diagnostic X-ray and lab exams are subject to a $15 copayment per visit*
• Well-baby and well-child care and immunizations, for children up to age 19
• Annual physical exam when rendered by a participating provider: Non-Medicare
  employees 45-64
• Physical and speech therapy*
• Nonroutine 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 percent of the allowed charge.
• Mammography and pap-smear screenings
• Private-Duty Nursing, covered in full when using a network provider.
• Allergy care*
• Outpatient mental health treatment
• Durable Medical Equipment (DME) paid-in-full when obtained through a network provider. $100 annual deductible per person. Precertification is needed for items over $2,000.

*Network medical providers/practitioners and mental health care providers have a $15 copayment per visit.

Here are a few of the providers who have a $15 copayment per visit:

Allergy	General Practice	Audiology
Geriatric Medicine	Bacteriology	Gynecology and Obstetrics
Cardiology	Hematology	Infectious Diseases
Chiropractor	Internal Medicine	Endocrinology
Medical Genetics	Family Practice	Neonatology
Gastroenterology	Certified Nurse Midwife

**Network surgeons, all surgical subspecialties and dermatologists have 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; Orthopedic and Hand Surgery; Otolaryngology; Plastic Surgery; Podiatry and Podiatric Surgery; Traumatic Surgery; Urology; Vascular and Veno Surgery.

Note: Benefits for covered services given by out-of-network providers have a $200 per person/$500 per family per yearly deductible. Reimbursement is based on the City of New York out-of-network provider schedule

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.

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

Hospital Benefits — Provided by Empire BlueCross BlueShield
Call 1-800-433-9592 or sign in to empireblue.com/NYC.

The GHI-CBP Optional Rider offers valuable additional benefits. If you need prescription drug coverage, the Optional Rider covers brand-name drugs and generic drugs at retail stores and has easy-to-use home delivery benefits.

Prescription Drug Benefit for Employees and non-Medicare Retirees
Retail pharmacy up to a 30-day supply (two fills) has a deductible of $150 per individual/$450 per family. After deductible, you pay:

• Generic — 20 percent coinsurance with a minimum charge of $5 or actual cost if less;
• Brand name Formulary — 40 percent coinsurance with minimum charge of $25 or actual cost if less;
• Brand name Non-Formulary — 50 percent coinsurance with minimum charge of $40 or actual cost if less.

If you choose a formulary or nonformulary brand that has a similar generic drug, you will pay the difference in cost between the drug and the generic coinsurance.

Mandatory Maintenance Mail Order
You can get up to a 60-day supply. You pay: $10 generic/$40 brand-name Formulary; $60 brand-name nonformulary. You must use home delivery for maintenance drugs. Prescriptions will not be filled at retail after two fills.

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

Out-of-Network Providers
An enhanced reimbursement schedule for certain surgical and in-hospital services when you use out-of-network providers.

Medical Benefits (GHI)
After you have paid the Medicare Part B deductible, you have $50 of covered Senior Care services per individual, per year. We then pay the Medicare Part B coinsurance (that is, 20 percent of Medicare allowed charges) for covered services for that year.

Please note that the separate $25 yearly deductible for private duty nursing, ambulance and DME will remain the same.

Hospital Benefits — Provided by Empire BlueCross BlueShield
Call 1-800-433-9592 or sign in to empireblue.com/NYC.

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/GHI Standard Part D program is available to City of New York retirees who also enroll in the City of New York GHI HMO Senior Supplemental program. The City of New York Enhanced and Standard Medicare Part D programs are Medicare drug plans. They are in addition to your coverage under Medicare, you need to keep your Medicare coverage. You can only be a member in one Medicare prescription drug plan at a time. For more details on our plans, see below:

• City of New York/GHI Enhanced Medicare Part D Prescription Drug Plan Summary of Benefits Brochure
• City of New York/GHI Standard Medicare Part D Prescription Drug Plan Summary of Benefits Brochure
• Formulary (list of covered drugs) information

Simply call 1-212-501-4444 in NYC or for customer service outside the NYC area and when asked by the recorded voice, enter your member ID. It's easy! The recording guides you through a menu of choices and you can choose the information or materials you need. You can use them to find a doctor, order claim forms and get other important information about your coverage.

This is a summary 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.