Revised Copayment Schedule for HIP Prime POS City of New York Benefit Plans

Date Issued: 6/24/2011

In order to minimize premium rate increases, changes will be made to our HIP Prime POS benefit plan for employees and retirees of the City of New York. In-network services and prescription drug benefits will change effective July 1, 2011. Out-of-network benefits will change beginning January 1, 2012.

In-Network Benefits 
Effective July 1, 2011, we will require copays for the following in-network services:

In-Network Benefit Current Copays Change to Copays 
July 1, 2011
Primary Care Physician (PCP) visit* $0 $5
Specialist visit* $0 $10
Emergency room (ER) visit** $0 $50
Inpatient hospital admission $0 $100

* $0 copay for preventive services 
** The $50 ER copay will be waived if member is admitted to the hospital.

Effective July 1, 2011, copays will change for members with the optional HIP rider for prescription drug benefits:

Prescription Drugs Current Copays Change to Copays 
July 1, 2011
Generic (30-day supply) $5 $10
Brand (30-day supply) $25 $35
Mail-order generic (90-day supply) $12.50 $15
Mail-order brand (90-day supply) $37.50 $52.50

Out-of-Network Benefits 
Out-of-network deductible, copay and coinsurance maximums remain the same until January 1, 2012. Members will continue to have an unlimited annual maximum and lifetime maximum benefit.

Effective January 1, 2012, out-of-network benefits will change:

Out-of-Network Current Cost-Share New Cost-Share
Annual Deductibles $250 / $500 $750 / $2,250
Coinsurance 80% / 20% 70% / 30%
Coinsurance Maximum $1,000 / $2,000 $3,000 / $9,000

Benefits Online 
Benefit summaries posted to our secure Web site will be updated for your reference. To view them, you may sign in to your Provider Account.

New Member IDs 
Look for new member ID cards on or after July 1, 2011. Remember to check ID cards and member eligibility at each visit to ensure you have the most up-to-date copayment information on file.