MEDICAL PLAN FOR RETIREES UNDER AGE 65, EFFECTIVE 1-1-99

MEDICAL PLAN FOR RETIREES UNDER AGE 65, EFFECTIVE 1-1-99

EMPIRE DELUXE PPO BENEFIT SUMMARY
BENEFIT	IN-NETWORK¹	OUT-OF-NET WORK²
^{COST SHARING}	Employee Pays	Employee Pays
^DEDUCTIBLE	Not Applicable	Option 1: $200/$500
^COINSURANCE	Not Applicable	30%
^{COINSURANCE STOP-Loss}	Not Applicable	$10,000/$25,000 ($3,000/$7,500 out-of-pocket)
^{DEPENDENT CHILDREN}	To age 19; full-time students to age 25
^{LIFETIME MAXIMUM}	Unlimited	$1 ,000,000

^{HOSPITAL BENEFITS}3	^{Employee Pays}	^{Employee Pays}
^INPATIENT4^{(Except Mental Health) Unlimited days-semiprivate room and board}	$0	Deductible and coinsurance
^{INPATIENT PHYSICAL THERAPY, PHYSICAL MEDICINE OR REHABILITATION}4 30 inpatient days per calendar year	$0	Deductible and coinsurance
^{MENTAL HEALTH}5 Up to 30 days per calendar year	$0	Covered in-network only
ALCOHOL/SUBSTANCE ABUSE^{5 Up to 7 days detox per calendar year}	$0	Covered in-network only
^{OUTPATIENT4 Ambulatory surgery , pre-surgical testing, chemotherapy, radiation therapy, mammography, and cervical cancer screening}	$0	Deductible and coinsurance
^{EMERGENCY ROOM/FACILITY Initial visit for emergency care4}	$35 copay (Waived if admitted within 24 hours)

^{OTHER FACILITY BENEFITS}3	Employee Pays	Employee Pays
^{ALCOHOL/SUBSTANCE ABUSE}5 Up to 60 outpatient visits which include 20 family counseling visits per calendar year	$0	Deductible and coinsurance
HOME HEALTH CARE^{4 Up to 200 visits per calendar year}	$0	Coinsurance (Deductible does not apply)
^{HOME INFUSION THERAPY}4	$0	Covered in-network only
^{OUTPATIENT KIDNEY DIALYSIS}	$0	Deductible and coinsurance
^HOSPICE4 Up to 210 days per calendar year	$0	Covered in-network only
SKILLED NURSING FACILITY^{4 Up to 60 days per calendar year}	$0	Covered in-network only

1Network provider delivers care.

2 ^{Subject to balance billing over allowed amount.}

3 ^{Out-of-network services (except Mental Health and
Alcohol/Substance Abuse) are those from a provider that does not participate with Empire
or with another Blue Cross and Blue Shield Plan through the BlueCard PPO Program.
[This does not apply to emergency benefits. See (5) for Mental Health and
Alcohol/Substance Abuse services.]}

4^{Precertification by our Medical Management Program is
required. If not obtained, penalties will apply.}

5^{Our Behavioral Health Care Management Program must
pre-approve all Mental Health and Alcohol/Substance Abuse services.}

6^{Copay does not apply if the Second Surgical Opinion is arranged
through our Medical Management Program.}

^{NOTE: This is a benefit summary only and is subject to the terms,
conditions, limitations, and exclusions set forth in the contract. Failure to comply with
our Medical Management or Behavioral Health Care Management Programs could result in
benefit reductions.}
^{PLEASE NOTE: A penalty of 50% of hospital and doctor bills on the
Empire Deluxe program up to a maximum of $2,500 per admission/visit if precertification is
not obtained.}

BENEFIT

IN-NETWORK 1

OUT-OF-NET WORK2

MEDICAL BENEFITS³

Employee Pays

Employee Pays

HOME/OFFICE VISITS

$12 copay (Network physician)

Deductible and coinsurance

ANNUAL PHYSICAL EXAM

$12 copay

Covered in-network only

WELL CHILD CARE (Up to age 19; including necessary immunizations)
$0

Deductible and coinsurance

WELL WOMAN CARE

$12 copay

Deductible and coinsurance

INPATIENT VISITS

$0

Deductible and coinsurance

DIAGNOSTIC SCREENING & MAMMOGRAPHY

$0

Deductible and coinsurance

MATERNITY

$0

Deductible and coinsurance

SURGERY

$0

Deductible and coinsurance

SURGICAL ASSISTANT

$0

Deductible and coinsurance

ANESTHESIOLOGY

$0

Deductible and coinsurance

LAB & X-RAY

$0

Covered in-network only

MRI⁴

$0

Covered in-network only

MENTAL HEALTH^{5

Up to 20 outpatient visits in office or facility per calendar year Up to 30 inpatient visits per calendar year}
^{$25 copay per visit}

^$0
^{Covered in-network only}

^{Covered in-network only}

ALLERGY TESTING & TREATMENT

$12 copay (Waived for treatments)

Deductible and coinsurance

SECOND SURGICAL OPINION

$12 copay6

Deductible and coinsurance

^{PHYSICAL THERAPY}4
Up to 30 visits as an inpatient & 30 visits combined in home, office, or outpatient facility
$12 copay

Covered in-network only

OTHER THERAPIES4 (Occupational, speech, vision) Combined 30 visits in home, office, or outpatient facility
$12 copay

Covered in-network only

CARDIAC REHABILITATION⁴

$12 copay

Deductible and coinsurance

MEDICAL SUPPLIES

Not applicable

$0

DURABLE MEDICAL EQUIPMENT, PROSTHETICS & ORTHOTICS⁴
$0

Covered in-network only

AMBULANCE

Not applicable

$0

CHIROPRACTIC CARE

$12 copay

Deductible and coinsurance

BENEFIT	IN-NETWORK 1	OUT-OF-NET WORK2

MEDICAL BENEFITS³	Employee Pays	Employee Pays
HOME/OFFICE VISITS	$12 copay (Network physician)	Deductible and coinsurance
ANNUAL PHYSICAL EXAM	$12 copay	Covered in-network only
WELL CHILD CARE (Up to age 19; including necessary immunizations)	$0	Deductible and coinsurance
WELL WOMAN CARE	$12 copay	Deductible and coinsurance
INPATIENT VISITS	$0	Deductible and coinsurance
DIAGNOSTIC SCREENING & MAMMOGRAPHY	$0	Deductible and coinsurance
MATERNITY	$0	Deductible and coinsurance
SURGERY	$0	Deductible and coinsurance
SURGICAL ASSISTANT	$0	Deductible and coinsurance
ANESTHESIOLOGY	$0	Deductible and coinsurance
LAB & X-RAY	$0	Covered in-network only
MRI⁴	$0	Covered in-network only
MENTAL HEALTH^{5 Up to 20 outpatient visits in office or facility per calendar year Up to 30 inpatient visits per calendar year}	^{$25 copay per visit} ^$0	^{Covered in-network only} ^{Covered in-network only}
ALLERGY TESTING & TREATMENT	$12 copay (Waived for treatments)	Deductible and coinsurance
SECOND SURGICAL OPINION	$12 copay6	Deductible and coinsurance
^{PHYSICAL THERAPY}4 Up to 30 visits as an inpatient & 30 visits combined in home, office, or outpatient facility	$12 copay	Covered in-network only
OTHER THERAPIES4 (Occupational, speech, vision) Combined 30 visits in home, office, or outpatient facility	$12 copay	Covered in-network only
CARDIAC REHABILITATION⁴	$12 copay	Deductible and coinsurance
MEDICAL SUPPLIES	Not applicable	$0
DURABLE MEDICAL EQUIPMENT, PROSTHETICS & ORTHOTICS⁴	$0	Covered in-network only
AMBULANCE	Not applicable	$0
CHIROPRACTIC CARE	$12 copay	Deductible and coinsurance