MEDICAL FEATURES

Deductible
Single deductible: this is the amount of Covered Expenses that the insured must incur each year before the plan pays benefits.

Family deductible: this is the amount of Covered Expenses that all the insured family members must incur each year before the plan pays benefits. Covered Expenses for all insured family members are added together and applied toward the Family Coverage Deductible before benefits are paid. When the Family Coverage Deductible applies, the Single Coverage Deductible does not apply. The Family Coverage Deductible is an aggregate amount that can be satisfied by one or any combination of family members incurring Covered Expenses toward this yearly amount.

Coinsurance
Coinsurance Limit: after the deductible is satisfied, the plan pays a percentage of the Covered Expenses up to the Coinsurance Limit. The Coinsurance Limit is the amount of Covered Expenses the insured must incur each year before the plan pays at 100% (the insured also shares in this expense up to the out-of-pocket maximum). Once the Coinsurance Limit is reached, the plan pays 100% of Covered Expenses for the balance of the year.

Maximum Benefit
The Maximum Benefit per insured is $5,000,000 per calendar year for all Covered Expenses incurred for all injuries, sicknesses or pregnancies. Benefits for Covered Expenses for certain care or services are limited. See Covered Expenses.

Covered Expenses
Covered Expenses include medical expenses incurred as a result of an injury, sickness or pregnancy for the following supplies and services. They also include expenses for certain routine examinations and preventive screening as described below. The expenses must be received while insured under the plan.

• Hospital expenses:
• Hospital room and board up to the semi-private room rate.
• Hospital supplies and services.
• Intensive care.
• Services of a licensed doctor, anesthetist, or a licensed or board certified psychologist. In-hospital doctors' visits are limited to four visits per two days.
• Services of a licensed physiotherapist or licensed occupational therapist, but only to restore or improve lost function following an injury or sickness.
• Services of a licensed physical therapist.
• Services of a qualified speech therapist for certain conditions.
• Services of a certified nurse-midwife under qualified medical direction, affiliated or practicing in conjunction with a facility licensed pursuant to Article 28 of the New York Public Health Law.
• Private duty nursing services. The Covered Expense is limited to $125 per day. And such services provided by a person who is also an employee of or affiliated with the Hospital or similar place in which the insured is an in-patient will not be a Covered Expense.
• Care for adults and children with biologically based mental illness.
• Care for children with serious emotional disturbances.
• Cognitive Rehabilitation Therapy for certain conditions.
• Care to manually detect and correct distortion, misalignment or partial dislocation of the spinal column and related physical therapy or treatment.
• Services provided as a hospital out-patient to treat an emergency condition.
• Services and medications used for non-experimental cancer chemotherapy and cancer hormone therapy.
• Preadmission tests performed in a hospital facility prior to scheduled surgery.
• Diagnosis and treatment of correctable medical conditions causing infertility, except for in vitro fertilization, gamete intrafallopian tube transfers (GIFT) or zygote intrafallopian tube transfers (ZIFT); reversal of elective sterilizations; sex change procedures; cloning; or medical or surgical services or procedures deemed experimental by the guidelines and standards established by the New York Superintendent of Insurance.
• Second surgical opinion by a qualified doctor on the need for surgery.
• Second medical opinion by an appropriate specialist in the event of (a) a positive or negative diagnosis of cancer; (b) a recurrence of cancer; or (c) a recommendation of a course of treatment for cancer.
• Equipment and supplies for the treatment of diabetes, if recommended or prescribed by a doctor or other licensed health care provider.
• Diabetes self-management education, including education relating to proper diets.
• Nutritional supplements (formula) as medically necessary for the treatment of phenylketonuria, branched-chain ketonuria, galactosemia, and homocystinuria when administered under the care of a doctor.
• Enteral Formula for home use as prescribed by a doctor or other legally licensed health care provider.
• Allergy tests for diagnosing disease.
• Lab tests.
• Mastectomy or lymph node dissection or lumpectomy, on the same basis as any other surgical procedure. Covered Expenses include in-patient care and reconstructive surgery.
• For pregnancy on the same basis as an illness, including in-patient care and post-discharge care.
• Adult Preventive Care services for doctors' office visits for routine physical exams, including routine injections, inoculations, immunizations, routine x-rays, laboratory tests and multiphasic screening based on the recommendations of the U.S. Preventive Service Task Force for adults age 19 or older. The plan pays 100% of these Covered Expenses up to $250 per year. Then the benefits are subject to the Deductible, Coinsurance, Coinsurance Limit and the Maximum Benefit. (For EPO Value plans there is no first dollar coverage. The benefit is subject to the Deductible and Coinsurance.).
• Mammography screening
  - Upon the recommendation of a physician, a mammogram at any age for insureds having a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer; and
  - a baseline mammogram for insureds age 35 but under 40 years; and
  - a mammogram once a year for insureds 40 years of age or older.
• An annual cervical cytology screening for women age 18 or older.
• An annual colorectal cancer screening starting at age 50.
• Preventive and Primary Care Services from birth up to age 19 for an initial hospital checkup and well child visits in accordance with the recommendations of the American Academy of Pediatrics. The visits include a medical history, a complete physical examination, development assessment, anticipatory guidance, and appropriate immunizations and laboratory tests. Also covered are the necessary immunizations in accordance with the recommendations of the Advisory Committee on Immunization Practices (ACIP). The plan pays 100% of the Covered Expenses. No Deductible or Coinsurance applies to any of these services.
• Bone density tests, drugs and devices approved by the Federal Food and Drug Administration for the detection of osteoporosis for women at significant risk of osteoporosis.
• Prostate cancer screening, including a digital rectal examination and a prostate-specific antigen (PSA) test as follows:
  - at any age for men with a prior history of prostate cancer; and
  - once a year for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors; and
  - once a year for men age 50 and over who are asymptomatic.
• Diagnostic x-ray exams.
• X-ray, radium and radioactive isotope therapy.
• Prescription drugs and prescription medicines.
• “Off-label use” of prescription drugs for the treatment of cancer.
• Artificial limbs and eyes, and their repair or (at our option) replacement.
• Casts, splints and surgical dressings.
• Orthopedic appliances (such as trusses, crutches and braces).
• Rental or purchase (at our option) of medical appliances and durable medical equipment up to $10,000 during the insured’ s lifetime. (Not a Covered Expense under the EPO Advantage and EPO Value plans.).
• Whole blood or blood plasma, unless it is replaced by or for the insured.
• Oxygen and the rental of equipment for giving it.
• Anesthesia and fluids needed for surgery.
• Prehospital emergency medical services for the treatment of an emergency condition provided by a local ambulance service.
• Transportation by rail, ambulance, or plane to the nearest hospital for specialized treatment up to $2,500 per confinement.
• Services provided by an Ambulatory Surgical Center.
• Services provided by a Birthing Center.
• •Home Health Care if a doctor prescribes home care in lieu of a hospital confinement.
• Convalescent Facility Care for up to 90 days, and limited to 50% of the daily semi-private room rate of the Hospital in which the insured was previously confined. This care is eligible if the admission is within 14 days of a 3-day minimum hospital confinement, and the insured continues to remain under the doctor’s care.
• Hospice Care benefits for a maximum of 210 days for inpatient and outpatient care, and up to 5 visits for all family members combined for bereavement counseling.
• Mental Health Care.
  - Inpatient Care for 30 days per year. Each day of covered inpatient care may be exchanged for 2 days of partial hospitalization.
  - Outpatient Care for up to 20 visits per year.
• Alcoholism, Alcohol Abuse, Substance Abuse, Chemical Abuse, and Chemical Dependency.
  - Inpatient Care for 30 days plus 7 days detoxification per year.
  - Outpatient Care for 60 visits per year. 20 of the visits may be for family members.
• Foot Care up to $2,000 per year for an open cutting operation to treat weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, and/or the removal of nail roots, and the treatment of corns, calluses or toenails in connection with a metabolic or peripheral vascular disease.
• Organ Transplant benefits up to $250,000 lifetime maximum benefit. (For EPO Advantage plans the lifetime maximum benefit is $150,000. For EPO Value plans the lifetime maximum benefit is $100,000.).

Extension of Benefits
If a person is totally disabled when insurance terminates, he or she remains protected for the illness or injury causing the total disability while the disability continues up to a period of 12 months, or he or she becomes insured for that illness or injury under any other group health plan which is arranged through an employer.

Coverage Continuation
The continuation of coverage required by New York law is provided for groups not subject to the requirements of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). The continuation of coverage required by COBRA is provided for all other groups.

Conversion privilege:
A conversion privilege is available for insured employees and dependents, except on plan termination when the plan is replaced by similar group coverage.

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