Schenectady City School District HEALTH BENEFIT COMPARISON ALL PLANS

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1 FEATURES Members can choose to go to ANY PROVIDER or HOSPITAL they choose. Out of pocket expenses will always be lower when using in-network providers and facilities. To find a provider visit All routine or scheduled medical care must be provided through CDPHP providers. In an emergency or urgent care situation, non-participating providers may be used as long as it is medically necessary. All routine or scheduled medical care must be provided through MVP providers. In an emergency or urgent care situation, non-participating providers may be used as long as it is medically necessary. NETWORK OF PROVIDERS In-Network benefits are paid when members choose to use the Blue Shield national network, which includes over 686,000 Providers, and over 6,000 hospitals. When using out of network providers, benefits will be paid under the Out-of-Network schedule of benefits. CDPHP has a comprehensive network of providers & hospitals in the 24 county service area in NYS. To find a provider visit MVP s service area of providers & hospitals extends to 27 Upstate NY counties. To find a provider visit DEDUCTIBILES & CO-PAYMENTS Out of Network: Deductibles Individual: $200 Two Person $300 Family $400 After deductible is met members pay 20% coinsurance. There are no deductibles. There may be a $15 co-pay for some services as indicated in this comparison. $50 copay for emergency room and $25 copay for participating urgent care facilities. There are no deductibles, $15 co-pay for some office services as indicated in this comparison. $50 co-pay for emergency room and a $15 co-pay for urgent care facilities.

2 BENEFITS-PREVENTIVE CARE IN DOCTOR S OFFICE Annual Physicals Routine GYN Exams Hearing Exams Immunizations Well Baby Care In-Network: Adult Annual Physical up to $300. (May vary depending on collective bargaining unit agreement) Well-child care covered 100%. Out of Network: 80% UCR. Well-child care covered 100%., 1 routine per year. after $200/$300/$400 deductible is met. 1 routine per year. ; no routine coverage; Medically necessary routine exam covered in full under well-child. No routine coverage; Medically necessary; covered in full under well-child. In-Network: (Adults) Not covered for routine. Adults require medical necessity. Well-child care covered in full. Out of Network: Not covered for routine. Well-child care 100%. In-Network:. Scheduled visits birth to age 19. Out of Network:. Scheduled visits birth to age 19.. Well-child care is covered 100% in accordance with schedule. after $15 co-pay. after $15 co-pay. Referral required. ; contact member services for criteria and limitations.. Scheduled visits birth to age 19. after $15 co-pay. Wellchild care is covered 100% in accordance with schedule. after $15 co-pay. Two routine self-referrals per year to a participating gynecologist. after $15 co-pay. ; contact member services for criteria and limitations.. Scheduled visits birth to age 19.

3 CHIROPRACTIC SERVICES HOSPITAL BENEFITS INPATIENT Room & Board Surgery 2 nd Surgical Opinion Physicians Visits Maternity Newborn Care ; 15 visits per calendar year. No referral. after deductible, 15 visits per calendar year, not subject to review. In-Network: Out of Network: 100%, after $100 copay (semi-private room) In-Network: Out of Network: Out of Network: 20% co-insurance Out of Network: 20% co-insurance In-Network: Out of Network: 20% co-insurance In-Network: Out of Network: after $15 co-pay. for unlimited days and dollar amounts when medically necessary. after $15 co-pay. after $15 co-pay to participating provider. for unlimited days and dollar amounts when medically necessary. after $15 co-pay.

4 HOSPITAL BENEFITS OUTPATIENT Surgery Diagnostic X-Ray & Laboratory Services Emergency Care Pre-Admission Testing Radiation Therapy Chemotherapy Physical Therapy Speech Therapy Out of Network: 80% UCR In-Network: $50 co-pay applies to non-emergency diagnosis. Paid in full with emergency diagnosis. Out of Network: 20% UCR ; 40 (In & Out of Network combined) visits per year for home care including home infusion therapy. after deductible. 40 visits per year. ; 40 (In & Out of Network combined) visits per year for home care including home infusion therapy. after deductible. 40 visits per year. $15 co-pay/day/facility $75 co-pay $15 co-pay Diagnostic labs covered in full; $15 copay per visit for X-ray services. when medically except for $50 co-pay necessary after $50 co-pay when when not followed by hospitalization. treated in the emergency room not Co-payment waived if admitted. $50 followed by hospitalization. Co-pay co-pay applies for out of network. waived if admitted. Up to 120 days per unrelated diagnosis per calendar year. Limited to services which will produce significant improvement within the 120-day treatment period. $15 co-pay/visit. Up to 60 days per unrelated diagnosis. $15 co-pay per visit. $15 co-pay per visit; 30 day s maximum per member per year; combined benefit for PT/OT/ST. $15 co-pay per visit; 30 day s maximum per member per year; combined benefit for PT/OT/ST.

5 MENTAL HEALTH CARE PRESCRIPTION DRUGS DURABLE MEDICAL EQUIPMENT & PROSTHETIC APPLIANCES AMBULANCE SERVICE MUST BE MEDICALLY NECESSARY & REQUIRED AS A RESULT OF AN EMERGENCY SKILLED NURSING FACILITY ROUTINE EYE EXAMS & EYEWEAR coverage after deductible. In-Network Only: RETAIL: 20% co-insurance MAIL ORDER: 16% co-insurance In-Network: 20% co-insurance coverage; Air ambulance only covered in network. coverage; 60 days per calendar year. Out of Network: 100% after $100 copay; 60 days per calendar year. (annually) Empire Vision Frames: $20 co-pay; 100%, Contacts: $45 co-pay; Out of Network: $35 co-pay after deductible is met. Frames: $35 allowance after deductible. Contacts: $90 allowance after deductible. Inpatient covered in full. Outpatient $15 co-pay Retail - $5 generic/$20 brand preferred /$35 brand non preferred at any participating pharmacy, per 30 day supply. Mail Order - for maintenance drugs 90 day supply $12.50/$50/$ % co-insurance; must be ordered by a participating provider and approved by CDPHP. $50 co-payment for a licensed ambulance. for up to 90 days per calendar year in a semi-private room in lieu of further hospitalization; must be ordered by a participating physician after hospital stay for the same accidental injury or illness. Yes. Every 24 months. $15 co-pay. In Network Only. Inpatient covered in full. Outpatient $15 co-pay Retail - $5 generic/$20 brand preferred /$40 brand non preferred at any participating pharmacy, per 30 day supply. Mail Order - available for maintenance drugs 90 day supply $10/$40/$80. after 20% coinsurance for purchase or rental of DME. Must be authorized by participating MVP physician. in lieu of hospitalization for 60 days per calendar year when pre-approved by MVP. once every two years after $15 co-pay. Frames: N/A Contacts: N/A

6 Provider Freedom of Choice YES NO NO Coordination of Benefits YES NO NO National Network Over 686,000 medical providers, 6,000 hospitals, 110,000 dental providers. Dependent Coverage Medical: Covers dependent to age 26. Dental: Covers dependent to age 19, to age 25 if full-time student. DENTAL PLANS Medical & hospital providers half the size of the self-funded plan. Only local providers. Medical: Covers dependent to age 26. Dental: Covers dependent to age 19, to age 25 if full-time student. Medical & hospital providers half the size of the self-funded plan. Only local providers. Medical: Covers dependent to age 26. Dental: Covers dependent to age 19, to age 25 if full-time student. Delta Dental Plan Guardian Dental Plan MVP Dental Coverage In-Network: Preventative (spacers, prophylaxis, etc.) 20% co-insurance. Basic (fillings, extractions, etc.) 20% co-insurance. Major (periodontal, crowns, etc.) 20% co-insurance. MEMBER CAN GO TO ANY DENTIST ANNUAL LIMIT - None Out of Network Deductibles: $200 per person $400 family maximum No Orthodontics In-Network: Preventative (spacers, prophylaxis, etc.) 100% coverage Basic (fillings, extractions, etc.) 20% co-insurance. Major (periodontal, crowns, etc.) 50% co-insurance. Out of Network: Basic (fillings, extractions, etc.) 50% co-insurance. Major (periodontal, crowns, etc.) 75% co-insurance. MEMBER CAN GO TO ANY DENTIST ANNUAL LIMIT $2,000 per member No Orthodontics Fee schedule with balance billing to member. MEMBER CAN GO TO ANY DENTIST ANNUAL LIMIT $1,500 per member No Orthodontics

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