Cs Plus Nyc Area Epo 2q 2009

2Q09 NYC AREA EPO PLANS Counties Include: Manhattan, Brooklyn, Queens, Bronx, Staten Island, Westchester, Rockland, Orange, Nassau, Suffolk, Putnam, Dutchess

Empire Prism EPO

HealthNet EPO

Oxford EPO

GHI EPO

Primary Care Specialist Care Preventative Care

$35 $35 $0

$25 $40 $0

$20 $40 $0

$30 $30 $0

Hospital Services Inpatient ER Visit Outpatient Surgery

$500 $100 $300

$500 $100 $75

$200 $75 $40

$500 $100 $250

Prescriptions Co-pay Cap or Deductible

10/35/70 $50 ded

10/30/50 None

10/25/50 $50 ded

0/30/50 None

D- 23 S- 25 Yes Yes Yes

Both to 19

D- 19 S- 23 Yes Yes Yes

Both to 19

Physician Services

Other Riders Dependent/Student Rider Domestic Partner Mental Health Parity Pre-Existing Cond. Excl.

Yes Yes Yes

Yes Yes Yes

Rates Individual $383.76 $389.25 $489.30 $440.20 Emp/Spouse $820.76 $866.90 $1076.46 $968.37 Emp/Child $738.16 $723.01 $906.71 $839.31 Family $1265.76 $1163.38 $1518.84 $1302.53 **This Proposal is for informational purposes only and is only a sample of some of the benefits covered. Please contact Council Services Plus for a formal offer and full listing of benefits