COOPERSTOWN CHAMBER OF COMMERCE

2008 CDPHP HMO $25/$40 Benefit Summary

Services Copayment

Physician Services Office visits for illness or injury, or second opinion Specialist office visit Physician visits during inpatient stay Well baby and child care, including immunizations/inoculations Annual adult exam Annual gynecological exam	$25 per visit $40 per visit Covered in Full Covered in Full Covered in Full Covered in Full
Hospital Services Inpatient hospital (semi-private room, anesthesia, X-ray, lab tests, etc.) Outpatient surgery	$500 $75
Diagnostic Testing 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	$40 $40 Covered in Full Covered in Full Covered in Full
Maternity Physician services Inpatient hospital services Newborn nursery	Covered in Full $500 Covered in Full
Emergency Care Worldwide emergency room care Ambulance	$100 (waived if admitted) $100
Urgent care – Non participating Urgent Care facility services within CDPHP’s service area not covered	$25 plus $10
Physical Therapy (up to 30 visits per benefit period)	$40
Speech Therapy (up to 20 visits benefit period)	$40
Occupational Therapy (up to 30 visits each per benefit period)	$40
Chiropractic Benefits	$40
Home Health Care	Covered in Full
Skilled Nursing Facility – up to 45 days per benefit period	$500
Prosthetic Devices and Durable Medical Equipment (DME)	50%
Diabetic Care Insulin and oral medications - up to 30 day supply Diabetic supplies (needles, syringes, etc.) - up to 30 day supply Glucometers Diabetic DME	$15 $15 $15 $15
Mental Health Services 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	$40 $500
Chemical Abuse and Dependency Treatment Services Outpatient Services, up to 60 visits per calendar year Inpatient Detoxification Services, Up to 7 days per benefit period Inpatient Rehabilitation Services, up to 30 days per benefit period	$25 per visit $500 $500
Dependent Coverage	Full time students Up to age 25
CDPHP gives you access to more than 9,000 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 CDPHP’s 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 Capital District Physicians’ Health Plan, Inc. (CDPHP) participating physician/provider (including hospital admissions) unless otherwise preauthorized by CDPHP.