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2Q09 NYC AREA EPO PLANS

Counties Include: Manhattan, Brooklyn, Queens, Bronx, Staten Island, Westchester, Rockland, Orange, Nassau, Suffolk, Putnam, Dutchess

Empire HealthNet Oxford GHI


Prism EPO EPO EPO
EPO

Physician Services
Primary Care $35 $25 $20 $30
Specialist Care $35 $40 $40 $30
Preventative Care $0 $0 $0 $0

Hospital Services
Inpatient $500 $500 $200 $500
ER Visit $100 $100 $75 $100
Outpatient Surgery $300 $75 $40 $250

Prescriptions
Co-pay 10/35/70 10/30/50 10/25/50 0/30/50
Cap or Deductible $50 ded None $50 ded None

Other Riders
Dependent/Student Rider D- 23 Both to 19 D- 19 Both to 19
S- 25 S- 23
Domestic Partner Yes Yes Yes Yes
Mental Health Parity Yes Yes Yes Yes
Pre-Existing Cond. Excl. 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