Cooperstown
Chamber of Commerce
2008 EPO
RIDERS
Domestic Partner
Provides
coverage for an eligible same or opposite sex domestic partner and his or her
eligible dependent children. Supporting documentation is required.
Skilled Nursing Facility
Extends skilled nursing facility
benefit to 365 days per benefit period subject to deductible then coinsurance.
Chemical
Abuse
Adds
7 days per benefit period for inpatient detoxification and 30 days
rehabilitation per benefit period for chemical abuse and dependency treatment,
including all facility, diagnostic and physicians’ charges, subject to
coinsurance, not subject to deductible. Inpatient chemical abuse and dependency
detoxification and rehabilitation services are not covered Out-of-Network.
Vision
One routine eye exam is covered every 24 months subject to deductible and copayment or coinsurance.
Prescription
Prescription
drug benefits as follows:
· $4 copayment for 30-day
supply of covered generic drugs.
· 50% coinsurance for brand
named drugs .
· Mail order: 2.5 copayments
for a 90-day supply.
· Prescriptions must be
written by a duly licensed health care provider and filled at a participating
pharmacy, unless otherwise authorized in advance by CDPHP.
· Specialty drugs require
preauthorization and must be obtained at CDPHP’s participating specialty
vendors.
Medicare Split Rider
A dependent spouse of a Medicare-eligible subscriber may enroll as a subscriber providing he or she is not Medicare-eligible.
Provides
coverage for preventive dental benefits for children and adults at a $10
copayment.
This
summary does not detail all benefits, limitations or exclusions. This is not a
contract and may be subject to change. Membership Certificate is available for
your review upon request. All benefits are subject to coordination of benefits
(COB).