2008 Chamber EPO $25 Transitional Plan Benefit Summary

Your Out-of-Pocket Responsibility

Annual Deductible	$500 single, $1,250 family
Coinsurance	20%
Coinsurance Maximum	$2,000 single, $5,000 family
Visit Copayment	$25
Annual Benefit Maximum	$1,000,000
Physician Services (not subject to the deductible) Office visits for illness or injury, or second opinion Well-baby and well-child care, including immunizations/inoculations Annual adult exam Annual gynecological exam	$25 copayment Covered in full Covered in full Covered in full
Hospital Services Inpatient hospital (semi-private room, anesthesia, X-ray, lab tests, etc.) Physician visits during inpatient stay Outpatient surgery	Deductible then 20% Deductible then covered in full Deductible then 20%
Diagnostic Testing (not subject to the deductible) Laboratory services (copayment waived if provider is a designated laboratory) Radiology and imaging (X-rays, ultrasounds, CT scans, etc.) (copayment waived at designated sites) Mammogram Cytology screening Prostate cancer screening	$25 copayment $25 copayment Covered in full Covered in full Covered in full
Maternity Physician services Inpatient hospital services Newborn nursery	Deductible then 20% Deductible then 20% Deductible then covered in full
Emergency Care Worldwide emergency room care Ambulance	Deductible then 20% (coinsurance waived if admitted) Deductible then 20%
Urgent care – nonparticipating Urgent Care facility services within the CDPHP UBI service area are not covered	Visit copayment plus $10 (not subject to the deductible)
Physical Therapy (up to 30 visits per benefit period)	$25 (not subject to the deductible)
Speech Therapy	Not covered
Occupational Therapy (up to 30 visits each per benefit period)	$25 (not subject to the deductible)
Chiropractic Benefits	$25 (not subject to the deductible)
Home Health Care	Deductible (not to exceed $50) then 20%
Skilled Nursing Facility	Subject to Deductible & Coinsurance up to 365 days
Prosthetic Devices and Durable Medical Equipment (DME) (not subject to deductible)	50% coinsurance $25,000 lifetime maximum
Diabetic Care (not subject to deductible) Insulin and oral medications – up to 30 day supply Diabetic supplies (needles, syringes, etc.) – up to 30 day supply Glucometers Diabetic DME	$15 copayment $15 copayment $15 copayment $15 copayment
Mental Health Services (not subject to deductible) Outpatient mental health, up to 20 visits per benefit period Inpatient mental health, up to 30 days per benefit period Biologically based mental illness and coverage for children with serious emotional disturbance is available beyond those limits for outpatient and inpatient services	$25 copayment 20% coinsurance
Chemical Abuse and Dependency Treatment Services (not subject to deductible) Outpatient services, up to 60 visits per calendar year Inpatient detoxification services Inpatient rehabilitation services	$25 copayment Not covered Not covered
Dependent Coverage	Up to age 19
CDPHP UBI gives you access to more than 8,000 participating practitioners and providers, many of the major hospitals, and a variety of value-added services to help you and your family stay healthy. If you have a question or wish to receive additional information, please contact the CDPHP UBI marketing department at (518) 641-5000 or 1-800-993-7299 or visit our Web site at www.cdphp.com. All benefits of this Plan are subject to coordination of benefits. This summary is designed to highlight the benefits of the plan being offered and does not detail all benefits, limitations, or exclusions. It is not a contract and may be subject to change. For more detailed information, a membership certificate is available for your review upon request. Please note: All non-emergency health services must be provided by a CDPHP Universal Benefits, Inc. (CDPHP UBI) participating physician/provider (including hospital admissions) unless otherwise preauthorized by CDPHP UBI.